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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600646
Report Date: 09/15/2022
Date Signed: 09/15/2022 03:53:31 PM

Document Has Been Signed on 09/15/2022 03:53 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
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:MANALO'S BOARD AND CARE VFACILITY NUMBER:
415600646
ADMINISTRATOR:MANALO, JOSEFINAFACILITY TYPE:
740
ADDRESS:840 ALTA LOMA DRIVETELEPHONE:
(650) 868-1901
CITY:SOUTH SAN FRANCISCOSTATE: CAZIP CODE:
94080
CAPACITY: 6CENSUS: 6DATE:
09/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Medel PahoyoTIME COMPLETED:
04:00 PM
NARRATIVE
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On this day Licensing Program Analysts (LPA) Jaime Vado conducted an unannounced infection control annual inspection visit. LPA met with facility staff and let him know the purpose of today's visit. Upon entry LPAs temperature was not taken and was not asked COVID questions.

LPA toured the physical plant inside and out. There are no accessible bodies of water or fire safety hazards observed. LPA did observe Lysol disinfectant spray on the floor in the backyard near the door entering the facility. COVID postings are present at front door and through out the facility. Hand washing signs are present in bathrooms. Hand sanitizer is observed as readily available through out the facility. Facility ambient temperature is warm and comfortable, and lighting is sufficient for residents and staff safety. Medication cabinet is observed as in order and door is locked. First aid kit is observed as in place in kitchen cabinet. Toilet and bathing facilities are equipped with grab bars and some showers equipped with non-slip mats. Liquid soap is available. Paper towels are present for resident use. LPA observed Comet cleaning powder and Lysol disinfectant spray in both bathrooms. Water temperature is taken in both common bathrooms. Front bathroom water temperature is measured at 140F and the rear bathroom the water temperature is measured as 136F. LPA observed 5 resident rooms and all had required furniture, lighting, linens and were in clean condition. Laundry machines and dryers are observed as functioning in the garage. Emergency food supply, dry goods, and perishables are observed as in place. Communal dining are is observed as in order. Fire extinguishers are charged ready for use. There is no inspection tag but according to the dial on the extinguishers observed adjacent to the kitchen and near the rear of the facility they are charged in the green range.

Infection control practices are reviewed: entry procedures, staff training and policies, resident monitoring, containment strategies, environmental preparation and cleaning. PPE supply is observed as in place. LPA reviewed training records and they are current. LPA sampled staff first aid cards and training records. Staff first aid cards are not current dated 1/27/2022 expiration date. Per staff person all staff has not had first aid training since the expiration. Training records are not current with the last training taking place in 2020 per staff file reviewed. Resident temperature log are current. Staff indicate they take daily temperatures but there is no log. All staff and residents are vaccinated according to the staff person. Facility only tests residents for COVID if symptoms are present.

A disaster and mass casualty plan is present and current. Criminal record clearances or exemptions for facility staff or other individuals are reviewed. Administrator certificate is not available for review. According to staff the mitigation plan and infection control plans are current.

LPA is requesting the following forms to be updated and sent to the Department by 9/22/2022:

• Copy of administrator Certificate
• LIC 308 Designation of Administrative Responsibility
• LIC 500 Personnel Report
• LIC 610D Emergency Disaster Plan

Report is reviewed with staff person. Citations are issued on the attached LIC809D pages.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Jaime Vado
LICENSING EVALUATOR SIGNATURE: DATE: 09/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/15/2022
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 3
Document Has Been Signed on 09/15/2022 03:53 PM - It Cannot Be Edited


Created By: Jaime Vado On 09/15/2022 at 03:25 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: MANALO'S BOARD AND CARE V
FACILITY NUMBER: 415600646

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/15/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/16/2022
Section Cited
CCR
87303(e)(2)

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Maintenance and Operation - Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C).
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Administrator shall ensure to submit evidence that the water temperature has been lowered to meet the regulatory baselines set of not being less than 105F and not more than 120F. The evidence of correction shall also include a plan indicating how this violation will not occur again in the future.
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This regulation has not been met as evidenced by: LPA tested water temperatures in two resident bathrooms, one at the front of the facility is tested at 140F, the other at the rear of the facility is tested at 136F.
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Type A
09/16/2022
Section Cited
CCR87309(a)

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Storage Space - Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.
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CORRECTED AND CLEARED DURING INSPECTION.
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This regulation has not been met as evidenced by: LPA observd Comet cleaning powder in both resident bathrooms as well as observing Lysol disinfectant spray. Lysol spray was also observed outside in the backyard adjacent to the door leading into the facility.
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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:Jackie Jin
LICENSING EVALUATOR NAME:Jaime Vado
LICENSING EVALUATOR SIGNATURE:
DATE: 09/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/15/2022


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 09/15/2022 03:53 PM - It Cannot Be Edited


Created By: Jaime Vado On 09/15/2022 at 03:34 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: MANALO'S BOARD AND CARE V
FACILITY NUMBER: 415600646

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/15/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/22/2022
Section Cited
HSC
1569.69(b)(2)

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Staff training; legislative findings; contents - In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.
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Administrator shall ensure to submit a plan as well as evidence in continuing the annual training of all staff. Dates and names of attendees shall be included. A statement shall be received on the prevention of this lapse of training will occur in the future
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This regulation has not been met as evidenced by: During an audit of staff training LPA was told and provided documentation of training that last took place in February 2020 and no other training has been provided to meet the annual 20 hour training within the last year.
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Type B
09/22/2022
Section Cited
CCR87923(a)

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First Aid Requirements. All direct care staff and the facility manager shall have first aid training from persons qualified by agencies including, but not limited to, the American Red Cross.
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Administrator shall ensure to audit all staff first aid cards to ensure they are current. Licensee shall submit a statement and evidence ensuring the preveintion of staff first aid cards from expiring in the future and evidence that training and new cards have been issued.
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This requirement was not met as evidenced by: LPA checked first aid cards for staff and S1 first aid card expired on 1/27/22. Per staff all staff cards are expired as there has been not first aid training to renew since the last training.
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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:Jackie Jin
LICENSING EVALUATOR NAME:Jaime Vado
LICENSING EVALUATOR SIGNATURE:
DATE: 09/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/15/2022


LIC809 (FAS) - (06/04)
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