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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216801028
Report Date: 10/13/2021
Date Signed: 10/13/2021 02:11:31 PM

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:DRAKE TERRACEFACILITY NUMBER:
216801028
ADMINISTRATOR:RICARDO ROMEROFACILITY TYPE:
740
ADDRESS:275 LOS RANCHITOS ROADTELEPHONE:
(415) 491-1935
CITY:SAN RAFAELSTATE: CAZIP CODE:
94903
CAPACITY:130CENSUS: 111DATE:
10/13/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Administrator, Ricardo RomeroTIME COMPLETED:
02:30 PM
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License Program Analyst (LPA) Farhaan Sarangi arrived unannounced to conduct an Annual Required 1 year inspection of the facility. LPA was welcomed by front desk staff and Executive Director (ED)/Administrator, Ricardo Romero and granted access into the facility.

LPA toured the facility with ED, Ricardo Romero. Facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Fire Extinguisher was found to be last charged on October 2021 at the time of the visit. Facility smoke detectors are hard wired and sound directly to the fire station. Smoke detectors and fire sprinklers are inspected, and inspection records are current with the last inspection being conducted on September 2021. LPA observed individual Smoke and Carbon monoxide detectors that were found to be operational during the visit. There are emergency lights in many of the fixtures in the common areas of the facility that come on should a power outage occurs. Facility serves residents with dementia and has special care plan of operation and programming. Hot water temperature measured within Title 22 acceptable regulation of 105 to 120 degrees F in a vacant bathroom while touring. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations at the time of the visit. LPA toured the kitchen area with ED and learned that there are no provisions made for individuals/residents with special dietary needs. Food is available for residents any time of the day. There is a daily activity schedule for residents. Toxins are stored in a locked housekeeping room.

LPA advised facility to contact County Public Health and Community Care Licensing immediately if symptoms or COVID-19 + in the facility. Facility has sufficient Personal Protective Equipment (PPE). Facility is N95 Fit tested. 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, Ricardo Romero.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan SarangiTELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:

DATE: 10/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2021
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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