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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216801961
Report Date: 11/19/2021
Date Signed: 11/19/2021 10:22:26 AM

Document Has Been Signed on 11/19/2021 10:22 AM - 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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:CAREMAX, INC. - QUIETWOOD HOMEFACILITY NUMBER:
216801961
ADMINISTRATOR:YANG, WEI & LI,JUANFACILITY TYPE:
735
ADDRESS:490 QUIETWOOD DRIVETELEPHONE:
(415) 225-6868
CITY:SAN RAFAELSTATE: CAZIP CODE:
94903
CAPACITY: 4CENSUS: 4DATE:
11/19/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:55 AM
MET WITH:Licensee, Willie YangTIME COMPLETED:
10:45 AM
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Licensing Program Analyst (LPA), Farhaan Sarangi arrived at Caremax Inc.-Quietwood Home unannounced for the purpose of conducting a Required 1 year inspection. LPA was greeted at the door by Licensee, Willie Yang. Licensee granted access into the facility.

LPA and licensee toured the facility at 09:58 AM. The facility was clean and well organized. Smoke; fire; carbon monoxide all current. All exits unobstructed. Hot water tested at 118 F degrees. Client bathrooms and bedrooms were clean and adequately furnished. Food was inspected and found to be in adequate supply and stored in compliance with regulations. Disaster drill log current and reflects monthly disaster drills. Fire extinguishers were last inspected on November 2021. Hazardous materials and medications are locked and stored away. Sufficient linens and hygiene products available for the use of clients. Food stored in the kitchen refrigerator were properly stored as per regulations on this day at the time of the inspection. Dangerous items and toxins were stored inaccessible to clients. There was a supply of cleaners, hygiene products and paper products available for clients. The bathroom designated for clients at the facility were supplied with individual paper towels; hand soap dispenser was available. All client’s bedrooms have lighting & appropriate furnishings, and client’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 on site supply of PPE and off site supply of PPE. Staff have had all PPE training required and have had N95 Fit testing in September 2021.

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 Licensee, Willie Yang.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE: DATE: 11/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/19/2021
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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