<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216800503
Report Date: 08/30/2022
Date Signed: 08/30/2022 03:00:21 PM


Document Has Been Signed on 08/30/2022 03:00 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



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: 4DATE:
08/30/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH: Administrator, Maria Del Pilar De OlaveTIME COMPLETED:
03:15 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
At approximately 12:30PM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a 1-Year Required Visit and met with Administrator, Maria Del Pilar De Olave. The visit is focused on the Infection and Control Practices of this facility.

Upon arrival at the facility, LPA answered a standard COVID-symptom questionnaire. LPA could not check their temperature due to the facility needing a new thermometer. Administrator stated that they are getting a new thermometer today. LPA also viewed documentation of the Visitor Log which showed that facility keeps record of visitors at the facility and logs their temperature.

LPA conducted a walk-through of the facility and observed the following: COVID-19 signs were observed at the entry way and throughout the facility. Hand-washing signs were observed in the bathrooms and at sinks. Staff were observed to not be wearing a mask but immediately put one on when LPA requested. The facility was found to be clean and at a comfortable temperature with all exits free from obstruction.

Facility has a cleaning and disinfecting schedule that occurs at least one time per day. Facility has at least a 30-day supply of Personal Protective Equipment (PPE) and medication for Residents. Staff and Residents are screened daily for COVID-19 symptoms and it is logged into facility binders.

LPA and Administrator discussed N-95 Fit testing, Activities, and PPE. Facility has a plan in place if a staffing shortage were to occur.

Fire extinguishers were last serviced March 2022. Facility has a Central Pull Fire Alarm system that is directly connected to the Fire Department. Smoke and Carbon Monoxide detectors were tested and operational.

Continued on LIC-809C
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn FeliasTELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:
DATE: 08/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/30/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: SHALOM HOUSE
FACILITY NUMBER: 216800503
VISIT DATE: 08/30/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Continued from LIC-809

LPA requested the following documents to update facility file:
  • Administrative Organization (LIC 309)
  • Designation of Facility Responsibility (LIC 308)
  • Emergency Disaster Plan (LIC 610D)
  • Personnel Report (LIC 500)
  • Register of Clients/Residents (LIC 9020)
  • Liability Insurance

Administrator to submit Administrator's Certificate (expires 12/07/2022) for facility file once renewal training is completed.

Documents to be submitted to Community Care Licensing (CCL) by Friday, September 30, 2022

No Deficiencies cited during this inspection.

Exit interview conducted. Copy of report discussed and provided to Administrator. Signature on form confirms receipt of documents.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn FeliasTELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:

DATE: 08/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2