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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011400627
Report Date: 09/03/2021
Date Signed: 09/03/2021 02:48:53 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:ST. PAUL'S TOWERSFACILITY NUMBER:
011400627
ADMINISTRATOR:LINDE, MARYFACILITY TYPE:
741
ADDRESS:100 BAY PLACETELEPHONE:
(510) 835-4700
CITY:OAKLANDSTATE: CAZIP CODE:
94610
CAPACITY:320CENSUS: 225DATE:
09/03/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Elena Davidenko, AdministratorTIME COMPLETED:
03:00 PM
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On 9/3/2021 starting at 11:20 AM, Licensing Program Analysts (LPAs) Catherine Lin and Grace Luk arrived unannounced to conduct Infection Control Inspection. LPAs met with Administrators Elena Davidenko and Director of Resident's Health Service Angela Vamarripa at the second floor at 12:05pm.

During the Infection Control Inspection, LPAs toured facility with administrator including but not limited to front entrance, screening station, hand washing stations, bedrooms, common areas, activity rooms, dining areas, kitchen, and back patio. Facility has a sufficient 2-day perishable and one week non-perishable food supply. Facility has one entry point for universal screening for staff, residents and visitors. A sign-in policy, thermometer, and hand sanitizer were observed at screening station. LPAs were asked to sign-in with the Accushield machine after temperature checked. Cough/sneeze etiquette, face-covering, social distancing, and hand washing posters were observed throughout the facility. Facility staff were observed to be wearing proper PPE. Facility has a 30-day supply of PPEs maintained at central location.

Facility has a mitigation plan, emergency disaster plan, and maintains records of routine screening for residents, staff and visitors, resident's changing of health conditions, and N95 respirators fit testing for staff.


No deficiency cited during visit. Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Catherine LinTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 09/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2021
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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