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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 380504099
Report Date: 06/27/2022
Date Signed: 06/27/2022 11:41:24 AM


Document Has Been Signed on 06/27/2022 11:41 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, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066



FACILITY NAME:KIMOCHI HOMEFACILITY NUMBER:
380504099
ADMINISTRATOR:CHAN, LINDA ISHIIFACILITY TYPE:
740
ADDRESS:1531 SUTTER STREETTELEPHONE:
(415) 922-9972
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94109
CAPACITY:20CENSUS: 13DATE:
06/27/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Staff, Sandy IshiiTIME COMPLETED:
11:40 AM
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Licensing Program Analyst (LPA) Murial Han and Chief Deputy Director, Claire Ramsey conducted an unannounced annual required inspection. LPA met with staff, Sandy Ishii.

At 9:30 am LPA and Chief Deputy Director arrived at the facility and were greeted by staff. LPA observed COVID-19 signs posted at the facility entrance.

LPA and Chief Deputy Director were properly screened and toured the facility beginning in the front entrance where COVID-19 signs are posted. The water fountains on the 1st and the 2nd floor are block off by blue tapes with a sign stating, " Do not use; out of order" to ensure no one is using them. The dinning room has 4 long tables and the chairs that are spaced to promote social distancing. COVID-19 Infection Control signs are posted throughout the facility both in English and Japanese. There are signs in the elevator for social distancing and reminder no more than 2 people at the same time. There were residents watching TV on the 1st floor with social distancing and some were wearing face covering. The sofas on the 2nd floor Activity Room are marked with blue tapes to ensure social distancing is maintained. Hand washing stations were equipped with paper supplies and soaps and hand hygiene signs are posted around the faucets. The garbage cans are observed to be closed lids. The facility has designated an isolation room on the 2nd floor with an isolation cart set-up. PPE supplies are stored in the isolation cart on the 2nd floor, by the front entrance and in the staff break room. The bed rooms were observed to be furnished per Title 22 regulations. Beds were spaced at least 6 feet apart.

Medications are stored appropriately and inaccessible to resident, a comfortable temperature is maintained, lighting is sufficient for comfort and safety, food supply was checked and observed to be sufficient. First-aid kit is inspected and complete.

During today's inspection, LPA and Chief Deputy Director reviewed facility's daily COVID-19 screening logs for residents, staff and visitors.

The facility will submit the following documents by 6/28/2022:
LIC309, LIC308, LIC400, Administrator Certification, and LIC610E

No deficiency was cited today. This report was discussed and reviewed with staff. A copy was provided during visit.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:
DATE: 06/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/27/2022
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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