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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216800503
Report Date: 08/10/2021
Date Signed: 08/10/2021 09:08:28 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:SHALOM HOUSEFACILITY NUMBER:
216800503
ADMINISTRATOR:MARIA DEL PILAR DE OLAVEFACILITY TYPE:
740
ADDRESS:566 WAKEROBIN LANETELEPHONE:
(415) 491-0604
CITY:SAN RAFAELSTATE: CAZIP CODE:
94903
CAPACITY:5CENSUS: 3DATE:
08/10/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:08 AM
MET WITH:Administrator, Maria Del Pilar De OlaveTIME COMPLETED:
09:18 AM
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Licensing Program Analyst (LPA), Farhaan Sarangi arrived at Shalom House for the purpose of conducting a Required-1 year inspection. LPA was greeted at the door by Administrator, Maria Del Pilar De Olave. Administrator granted access into the facility.

LPA toured the facility on with Administrator, Maria Del Pilar De Olave. LPA observed the facility to be clean and at a comfortable temperature with all exits free from obstruction. Fire Extinguisher was found to be last charged on March 2021. Smoke detectors and Carbon monoxide detectors were found to be operational during the visit. Hot water temperature measured at 118 degrees in resident’s bathrooms while touring the facility. The facility serves residents with dementia and has a plan of operation for special care and programming. 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 a locked hallway closet. Medications were centrally stored in locked cabinet in the facility kitchen area. First aid kit was inspected and found to be appropriate. The bathrooms designated for residents at the facility were supplied with 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. Resident’s beds were outfitted with mattress pads as required by Title 22 Regulations.

LPA advised facility to contact County Public Health and Community Care Licensing immediately if symptoms or COVID-19 + in the facility. Facility has PPE supply stored in the outside storage. Staff have had all PPE training required and have been N95 Fit tested. Mitigation Plan reviewed at the facility.

No deficiencies were observed or cited during today's Required 1- Year inspection. Exit interview was conducted and a copy of this report was emailed to the facility Administrator, Maria Del Pilar De Olave.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan SarangiTELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:

DATE: 08/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2021
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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