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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385600397
Report Date: 03/20/2024
Date Signed: 03/20/2024 02:23:15 PM

Document Has Been Signed on 03/20/2024 02:23 PM - 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:SUNSET CARE HOMEFACILITY NUMBER:
385600397
ADMINISTRATOR:ZHANG, ALICE FENGFACILITY TYPE:
740
ADDRESS:1434 7TH AVENUETELEPHONE:
(415) 516-9368
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94122
CAPACITY: 15CENSUS: 14DATE:
03/20/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
09:08 AM
MET WITH:Alice Zhang, Licensee/AdministratorTIME COMPLETED:
02:30 PM
NARRATIVE
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On March 20, 2024, Licensing Program Analyst(LPA) John Calandra, arrived at the facility at 9:08 AM to complete the Annual Inspection started on February 23, 2024. LPA Calandra was greeted by Licensee/Administrator, Alice Zhang and explained the purpose of his visit.

A review of Centrally stored medications indicated that medications for residents were properly labeled with instructions on dosage and times of day and matched the Centrally Stored Medication records(CSMR) kept at the facility.

LPA Calandra reviewed 5 client records and 5 staff files. All resident files were observed to be complete however staff files were observed to be missing documents.

LPA Calandra interviewed 5 residents and 3 staff.

A Technical Violation was provided for not having documentation of quarterly emergency drills.

The Facility received a Type B Violation for not ensuring all personnel are in good health and physically and mentally capable of performing assigned tasks.

Deficiencies of the California Code of Regulations, Title 22 are cited on the LIC 809-D. Failure to correct the deficiencies may result in civil penalties

This report was reviewed with Alice Zhang, Licensee/Administrator and a copy of the report left at the facility.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: John Calandra
LICENSING EVALUATOR SIGNATURE: DATE: 03/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/20/2024
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 2
Document Has Been Signed on 03/20/2024 02:23 PM - It Cannot Be Edited


Created By: John Calandra On 03/20/2024 at 01:56 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: SUNSET CARE HOME
FACILITY NUMBER: 385600397

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(f)
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.

This requirement is not met as evidenced by:
Deficient Practice Statement
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CCR 87411 (f): Personnel Requirements-General: Based on record review, the licensee did not comply with the section cited above in 3 out of 5 staff files which did not include Health Screening Reports, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/03/2024
Plan of Correction
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Licensee/Administrator to submit proof of correction and a written plan outlining how this violation will be avoided in the future to licensing office 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:Cara Smith
LICENSING EVALUATOR NAME:John Calandra
LICENSING EVALUATOR SIGNATURE:
DATE: 03/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/20/2024


LIC809 (FAS) - (06/04)
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