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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601122
Report Date: 06/16/2022
Date Signed: 06/16/2022 08:59:44 AM

Document Has Been Signed on 06/16/2022 08:59 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
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:ARBOR HOUSEFACILITY NUMBER:
415601122
ADMINISTRATOR:ALEJANDRO, VICTORIAFACILITY TYPE:
740
ADDRESS:330 ARBOR DRIVETELEPHONE:
(510) 825-2287
CITY:SOUTH SAN FRANCISCOSTATE: CAZIP CODE:
94080
CAPACITY: 4CENSUS: 3DATE:
06/16/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:House Manager, Homer BautistaTIME COMPLETED:
09:15 AM
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On June 16, 2022, Licensing Program Analyst (LPA) Komal Charitra, conducted an unannounced case management visit. LPA met with House manager, Homer Bautista and Caregiver, Noel Elizaga, and explained the purpose of the visit.

During the complaint investigation 14-AS-20220222094818, LPA Charitra cited the facility for Section 87307(a)(2)Personal Accommodation and Services, as a result of the facility utilizing the garage as a sleeping area for staff. The facility’s plan of correction was to submit a new facility floor plan to CCLD to request for a new fire clearance.

On June 13, 2022, CCLD received the fire clearance request back from South San Francisco Fire Department, and it was indicated that sleeping in the garage is not allowed and that all sleeping items must be removed from the garage. During the visit today, LPA observed the couch still in the garage. According to the House Manager, there is still a staff member currently sleeping in the garage. The house manager indicated that the staff member will move all personal belonging in the facility van. In addition, the house manager indicated that the staff will be utilizing the facility van as a sleeping area.

Deficiency of the Residential Care Elderly California Code of Regulations, Title 22, Division 6 is observed and cited on a LIC809D. Failure to correct the deficiencies may result in civil penalties.

This report is reviewed and discussed with Homer Bautista; a copy of the report is provided with appeal rights.
SUPERVISORS NAME: Julio Montes
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE: DATE: 06/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/16/2022
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 06/16/2022 08:59 AM - It Cannot Be Edited


Created By: Komal Charitra On 06/16/2022 at 08:33 AM
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: ARBOR HOUSE
FACILITY NUMBER: 415601122

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/16/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/17/2022
Section Cited
CCR
87203

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87203 FIRE SAFETY: All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.

Violation of this regulation is not met as evidenced by:
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Facility will find alternative sleeping area for staff and notify and check with CCLD to ensure it meets CCR regulations.
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Based on observations and information collected, the licensee did not comply with the section cited above, as the garage was being used by staff for sleeping, which poses an immediate health, safety, or personal rights risk to persons in care.
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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:Julio Montes
LICENSING EVALUATOR NAME:Komal Charitra
LICENSING EVALUATOR SIGNATURE:
DATE: 06/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/16/2022


LIC809 (FAS) - (06/04)
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