380504134-5-19-2021-14-AS-MHAN-C377AT-20210519213004

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 380504134
Report Date: 05/19/2021
Date Signed: 05/19/2021 09:31:19 PM

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:	JULIE'S CARE HOME		FACILITY NUMBER:	380504134
ADMINISTRATOR:	CHAE, JULIE		FACILITY TYPE:	740
ADDRESS:	1363 - 5TH AVENUE		TELEPHONE:	(415) 566-4527
CITY:	SAN FRANCISCO	STATE: CA	ZIP CODE:	94122
CAPACITY:	14	CENSUS: 11	DATE:	05/19/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:08 PM
MET WITH:	Asst. Administrator, Sarah Chu		TIME COMPLETED:	03:00 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	Licensing Program Analyst (LPA) Murial Han and Licensing Program Manager (LPM) Gladys Kuizon conducted an unannounced annual required inspection. LPA and LPM met with the Assistant Administrator, Sarah Chu. At 1:08PM, LPA and LPM arrived at facility and were greeted by staff and the Assistant Administrator. LPA and LPM observed COVID-19 signs posted by the entrance foyer. LPA and LPM were properly screened by the staff. LPA and LPM reviewed the visitor screening log, the daily resident screening log, the training records and the employee testing system. The Assistant Administrator stated that the employees are screened daily but it is not documented. LPA and LPM recommended to create a log for proper documentation. LPA and LPM proceed with the tour of the facility beginning in the 2nd floor dining room and observed 1 long table against the wall and chairs that are spaced to promote social distancing. COVID-19 Infection Control signs are posted in the 1st and the 2nd floor dining rooms. LPA and LPM recommended to also post the signs in the Activity Room, and the hallways. There was 1 resident watching TV on the 2nd floor Activity room and 1 resident sitting by the entrance observed with no face covering. The Assistance Administrator stated that it is a challenge for the residents to have face covering but they will continue to encourage them to do so. All staff were observed wearing face covering. Hand washing stations were equipped with paper supplies and soaps but 2 of stations did not have the hand-washing sign posted. The Assistant Administrator stated that it was wet so she took them down and will replace them as soon as possible. The facility has designated one room and one bathroom on the 2nd floor to be the isolation room. LPA and LPM recommended to have an isolation cart set-up with PPE supplies and signs in front of the isolation room when isolation room is in use. Continued, see LIC 809-C.

SUPERVISOR'S NAME: Brenda Chan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 05/19/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2021

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: JULIE'S CARE HOME	FACILITY NUMBER: 380504134
	VISIT DATE: 05/19/2021

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In regards to PPE supplies, during the visit, the facility does not have an audit system in place to determine on how much PPE supplies is available. LPA Han and LPM Kuizon recommended to create PPE inventory log per usage and maintain at least 30 day supply.

The facility has an indoor and outdoor designated visitation area. Some trash bins were observed to have closed lids and some were not. LPA and LPM recommended to have all the trash bins with lids. The bed rooms were observed to be furnished per Title 22 regulations. Beds were spaced at least 6 feet apart or 3 feet apart with head-to-toe orientation. Food supply was checked and observed to be sufficient.

No deficiency was cited today. This report was discussed and reviewed with facility designee, Luzviminda Madraga. Due to technical difficulty, a copy of this report will be emailed to the Asst. Administrator.

SUPERVISOR'S NAME: Brenda Chan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 05/19/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2021

LIC809 (FAS) - (06/04)

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