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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601122
Report Date: 07/06/2023
Date Signed: 07/06/2023 04:47:28 PM

Document Has Been Signed on 07/06/2023 04:47 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:ARBOR HOUSEFACILITY NUMBER:
415601122
ADMINISTRATOR:ALEJANDRO, VICTORIAFACILITY TYPE:
740
ADDRESS:330 ARBOR DRIVETELEPHONE:
(510) 825-2287
CITY:SOUTH SAN FRANCISCOSTATE: CAZIP CODE:
94080
CAPACITY: 3CENSUS: 3DATE:
07/06/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:05 PM
MET WITH:Veronica RozarioTIME COMPLETED:
05:00 PM
NARRATIVE
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On 7/6/2023, Licensing Program Analyst (LPA) Grace Donato conducted a case management visit concerning an incident report received. LPA met with Lead Staff (LS) Veronica Rozario. LPA explained the purpose of today's visit.

On 7/5/2023, facility submitted an incident report concerning resident a resident (R1) was given a wrong medication.

During today's visit, LPA observed medications to be locked and inaccessible to residents. Residents were at the living room watching a movie.

In regard to the incident, LS stated that on the day the incident occurred, the staff (S1) was on NOC shift. S1 was giving out medication in the morning and accidentally gave the wrong set of medication to R1. R1 already ingested the medication so S1 called administrator to report and then poison control was called for advice.

S1 is currently not allowed to give out medications. S1 has medication training. Facility staff members will have training again in regard to resident medications.

Deficiency is cited today as the facility did not ensure that correct medications is given to residents.

Deficiency is cited under California Code of Regulations, Title, 22 cited on the LIC 809D. Failure to correct the deficiencies may result in civil penalties. Report was discussed with lead staff, Veronica Rozario. A copy of this report and the Appeal Rights are provided.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE: DATE: 07/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/06/2023
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 07/06/2023 04:47 PM - It Cannot Be Edited


Created By: Grace Donato On 07/06/2023 at 04:30 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: ARBOR HOUSE
FACILITY NUMBER: 415601122

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/06/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/07/2023
Section Cited
CCR
87411(d)(4)

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87411 Personnel Requirements – General
(d) All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance: (4) Knowledge required to safely assist with prescribed medications which are self-administered.
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The licensee and/or administrator will review the regulation, develop a plan to ensure this incident does not happen again. The plan needs to include on how to make sure that correct medication is given to residents.
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This requirement was not met as evidenced by caregiver did not ensure that the correct medication is given to the resident.
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In addition, the plan needs to include staff training. The administrator/licensee will provide a copy of such plan and a sign-in record of staff training to CCL by 7/7/2023.

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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:Grace Donato
LICENSING EVALUATOR SIGNATURE:
DATE: 07/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/06/2023


LIC809 (FAS) - (06/04)
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