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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
419210117
Report Date:
09/11/2024
Date Signed:
09/13/2024 08:46:56 AM
Document Has Been Signed on
09/13/2024 08:46 AM
- It Cannot Be Edited
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO
,
851 TRAEGER AVE., SUITE 360
SAN BRUNO
,
CA
94066
FACILITY NAME:
AMMA'S HOME
FACILITY NUMBER:
419210117
ADMINISTRATOR:
EVAILMALO, CALVIN
FACILITY TYPE:
735
ADDRESS:
624 VANESSA DRIVE
TELEPHONE:
(510) 282-5813
CITY:
SAN MATEO
STATE:
CA
ZIP CODE:
94402
CAPACITY:
4
CENSUS:
4
DATE:
09/11/2024
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
09:30 AM
MET WITH:
Anjeshni Andrade, Calvin Evaimalo, Godfred Garduce
TIME COMPLETED:
02:30 PM
NARRATIVE
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LPA Jeung toured facility and grounds. This is a single story facility with 4 private resident rooms, two full bathrooms, and a staff/office room. No accessible bodies of water or fire safety hazards observed. Alarm systems were installed on the resident doors at entry point and doors leading outside. In the kitchen, sharps and medications are locked and inaccessible to residents. PPE supply is adequate and food supplies are checked. A comfortable temperature is maintained, and lighting is sufficient for comfort and safety. Soap and paper towels are present in bathrooms and kitchen sink. First-aid kit is inspected and complete. A Disaster and Mass Casualty Plan is posted.
Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed.
Calvin Evaimalo and Godfred Garduce are certified ARF administrators that oversee facility operations.
The following licensing forms/information are requested to be sent to CCLD by 9/25/24:
- Administrative Organization (LIC309)
- Personnel Report (LIC500)
- Facility Sketch, including dimensions
- Proof of current surety bonding
- Emergency Disaster Plan (LIC610--9 page version, with signed and dated page 9)
Facility phone number is 650/931-4820 and will be corrected.
Deficiencies of the General Licensing Regulations, of the California Code of Regulations, Title 22, Division 6, are cited. See also Technical Advisory notes--3 pages.
SUPERVISOR'S NAME:
April Cowan
TELEPHONE:
(650) 266-8889
LICENSING EVALUATOR NAME:
Audrey Jeung
TELEPHONE:
(650) 266-8891
LICENSING EVALUATOR SIGNATURE:
DATE:
09/11/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
09/11/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809
(FAS) - (06/04)
Page:
1
of
4
Document Has Been Signed on
09/13/2024 08:46 AM
- It Cannot Be Edited
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO
,
851 TRAEGER AVE., SUITE 360
SAN BRUNO
,
CA
94066
FACILITY NAME:
AMMA'S HOME
FACILITY NUMBER:
419210117
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
09/11/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80019(e)(3)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 80019(f) or
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on staff records review, the licensee did not comply with the section cited above in 1 out of 5 staff files reviewed, which poses an immediate health, safety or personal rights risk to persons in care.
- Criminal record clearance for staff #2 is not associated to this facility.
POC Due Date:
09/11/2024
Plan of Correction
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Criminal Record Clearance Transfer Request for staff #2 is given to LPA with photo ID.
Deficiency corrected and cleared.
Section Cited
Deficient Practice Statement
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4
POC Due Date:
Plan of Correction
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2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:
April Cowan
TELEPHONE:
(650) 266-8889
LICENSING EVALUATOR NAME:
Audrey Jeung
TELEPHONE:
(650) 266-8891
LICENSING EVALUATOR SIGNATURE:
DATE:
09/11/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
09/11/2024
LIC809
(FAS) - (06/04)
Page:
2
of
4
Document Has Been Signed on
09/13/2024 08:46 AM
- It Cannot Be Edited
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO
,
851 TRAEGER AVE., SUITE 360
SAN BRUNO
,
CA
94066
FACILITY NAME:
AMMA'S HOME
FACILITY NUMBER:
419210117
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
09/11/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).
This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation, the licensee did not comply with the section cited above, as hot water temperature tested at 100 degrees in both bathrooms.i This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
09/25/2024
Plan of Correction
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Hot water temperature shall be increased and regulated to maintain temperature between 105 and 120 degrees. Proof of correction to be sent to CCLD BY DUE DATE.
Type B
Section Cited
CCR
80075(f)
Health-Related Services
(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.
This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on staff records review, the licensee did not comply with the section cited above in 2 out of 5 staff files reviewed, which poses a potential health, safety or personal rights risk to persons in care.
- Current first aid training is missing for Staff #1 and #4.
POC Due Date:
09/25/2024
Plan of Correction
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4
Proof of current first-aid training for staff #1 and #4 will be sent to CCLD BY DUE DATE.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:
April Cowan
TELEPHONE:
(650) 266-8889
LICENSING EVALUATOR NAME:
Audrey Jeung
TELEPHONE:
(650) 266-8891
LICENSING EVALUATOR SIGNATURE:
DATE:
09/11/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
09/11/2024
LIC809
(FAS) - (06/04)
Page:
3
of
4
Document Has Been Signed on
09/13/2024 08:46 AM
- It Cannot Be Edited
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO
,
851 TRAEGER AVE., SUITE 360
SAN BRUNO
,
CA
94066
FACILITY NAME:
AMMA'S HOME
FACILITY NUMBER:
419210117
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
09/11/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(k)(7)(A-H)
A record of centrally stored prescription medications for each resident shall be maintained and include names of the resident for whom prescribed, prescribing physician and pharmacist, drug name, strength and quantity, dates filled, started & expiration, prescription number and instructions:
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on review of clients' medications records, the licensee did not comply with the section cited above, as 2 Rx medications for client #1 are not recorded on Centrally Stored Medications Records, which poses a potential health, safety or personal rights risk to persons in care.
Rx Amitriptyline filled 7/6/24 and Fluoxetene filled 6/27/24 for client #1 are not recorded on CSMR.
POC Due Date:
09/11/2024
Plan of Correction
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2 Rx medications are recorded on CSMR in LPA's presence, Deficiency corrected and cleared.
Section Cited
Deficient Practice Statement
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3
4
POC Due Date:
Plan of Correction
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2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:
April Cowan
TELEPHONE:
(650) 266-8889
LICENSING EVALUATOR NAME:
Audrey Jeung
TELEPHONE:
(650) 266-8891
LICENSING EVALUATOR SIGNATURE:
DATE:
09/11/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
09/11/2024
LIC809
(FAS) - (06/04)
Page:
4
of
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