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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385601097
Report Date: 03/06/2025
Date Signed: 03/06/2025 01:59:28 PM

Document Has Been Signed on 03/06/2025 01:59 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:SUTRO HEIGHTS CORPORATIONFACILITY NUMBER:
385601097
ADMINISTRATOR/
DIRECTOR:
PACALDO, JULIETFACILITY TYPE:
740
ADDRESS:659 45TH STREETTELEPHONE:
(415) 571-8531
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94121
CAPACITY: 14CENSUS: 9DATE:
03/06/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:05 AM
MET WITH:Lea Pantango, Lead Staff & Julio Yap, CaregiverTIME VISIT/
INSPECTION COMPLETED:
02:15 PM
NARRATIVE
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On 3/6/2025, Licensing Program Analyst (LPA) Tobola conducted an unannounced Annual Required – 1 yr. inspection for this facility and was greeted by Lea Pantango and Caregiver Julio Yap. The facility currently provides care for 9 residents some of which with a diagnosis of dementia. LPA continued with a tour of the facility with staff, facility found to be clean and at a comfortable temperature with all exits free from obstruction. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguishers located throughout the facility were found to be charged. Smoke detectors were present in each common room and resident bedroom. Carbon monoxide detector located in hallways were tested an in working order. Emergency disaster plan is reviewed and completed.

There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations, with food stored in the kitchen refrigerator found to have appropriate coverings, enough for residents in care. There was a supply of hygiene products and paper products available for residents. Resident's bedroom have lighting & appropriate furnishings and bedding items. Restrooms for resident use were equipped with non-slip mats, grab bars and kept in good condition. During inspection, LPA observed container of powder bleach in resident restroom not kept in secured storage. Staff immediately removed the cleaning supply and stored properly. There is a large outdoor patio equipped with appropriate shading for resident use. Medications are stored in the kitchen and found to be secured. Upon spot review of medications, LPA found that the facility has centrally store medication records updated and in order. LPA conducted a sample file review for residents and found 3 resident appraisals not signed or completed. Upon a sample review of staff files LPA found that all caregiver staff have current 1st aid and CPR certification, annual training, health screening reports on file.

LPA requested the following documents be sent to CCL by COB 3/20/2024:

LIC 308 Designated Facility Responsibility LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan

Deficiency cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties.
SUPERVISORS NAME: Andrea Medlin
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE: DATE: 03/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/06/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/06/2025 01:59 PM - It Cannot Be Edited


Created By: Dominic Tobola On 03/06/2025 at 01:22 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: SUTRO HEIGHTS CORPORATION

FACILITY NUMBER: 385601097

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 03/06/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in LPA observed powdered bleach in resident restroom left unsecured and accessible which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/06/2025
Plan of Correction
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Administrator immediately removed cleaning supply and properly placed in secured location. Deficiency cleared at time of visit.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Andrea Medlin
LICENSING EVALUATOR NAME:Dominic Tobola
LICENSING EVALUATOR SIGNATURE:
DATE: 03/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/06/2025


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 03/06/2025 01:59 PM - It Cannot Be Edited


Created By: Dominic Tobola On 03/06/2025 at 01:22 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: SUTRO HEIGHTS CORPORATION

FACILITY NUMBER: 385601097

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 03/06/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(a)
Reappraisals
(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated, in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 3 out of 5 resident appraisals that were not signed or completed, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/13/2025
Plan of Correction
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Administrator agrees to review all resident appraisals and ensure they are completed and signed. Administrator to submit LIC9098 Proof of Corrections by POC date 3/13/2024, indicating all appraisals have been updated/completed.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Andrea Medlin
LICENSING EVALUATOR NAME:Dominic Tobola
LICENSING EVALUATOR SIGNATURE:
DATE: 03/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/06/2025


LIC809 (FAS) - (06/04)
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