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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 210104607
Report Date: 12/08/2021
Date Signed: 12/08/2021 10:32:14 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:DANIEL REST HOMEFACILITY NUMBER:
210104607
ADMINISTRATOR:DANIEL, SILVANAFACILITY TYPE:
740
ADDRESS:28 ROOSEVELT AVENUETELEPHONE:
(415) 479-5522
CITY:SAN RAFAELSTATE: CAZIP CODE:
94903
CAPACITY:6CENSUS: 5DATE:
12/08/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:17 AM
MET WITH:Administrator, Silvana DanielTIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA), Farhaan Sarangi arrived at Daniel Rest Home unannounced for the purpose of conducting a Required-1 year inspection. LPA was greeted at the door by Administrator, Silvana Daniel. Administrator granted access into the facility.

LPA and Administrator toured the facility at 09:45 AM. Facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Exits were equipped with auditory devices that were working properly during the visit; facility has no residents that wander at this time. Fire Extinguisher was found to be last charged on 02/2021 at the time of the inspection. Smoke detectors and carbon monoxide detectors were found to be operational during the visit. Hot water temperature measured at 110 degrees F within Title 22 acceptable regulation of 105 to 120 degrees F in 3 out of 3 resident’s bathroom faucets while touring facility. The facility serves residents with dementia and has a plan of operation for special care and programming. There was a sufficient supply of both perishable and nonperishable food as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations on this day at the time of the visit. Toxins are stored in the garage. There was a supply of cleaners, hygiene products and paper products available for residents. The bathroom designated for residents at the facility were supplied with individual towels and hand soap dispensers. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present in the bathroom shower. All bedrooms have lighting & appropriate furnishings. LPA requested the most up to date Liability Insurance.

LPA advised facility to contact County Public Health and Community Care Licensing immediately if symptoms or COVID-19 + in the facility. Facility has sufficient PPE supplies. Staff have had all PPE training required and are in the process of obtaining N95 Fit testing.

Exit interview was conducted and a copy of this report signed and emailed to the Administrator, Silvana Daniel.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan SarangiTELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:

DATE: 12/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2021
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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