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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 380504185
Report Date: 09/24/2021
Date Signed: 09/24/2021 05:16:48 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:GUIROLA RESIDENT CAREFACILITY NUMBER:
380504185
ADMINISTRATOR:GUIROLA, JOSE & TEODORAFACILITY TYPE:
740
ADDRESS:618 HOLLOWAY AVENUETELEPHONE:
(415) 334-6498
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94112
CAPACITY:6CENSUS: 4DATE:
09/24/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Administrator, Teodora GuirolaTIME COMPLETED:
11:30 AM
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On 9/24/2021, Licensing Program Analyst(LPA) Murial Han conducted an unannounced annual inspection. LPA was greeted by the Administrator, Teodora Guirola. LPA explained the purpose of the visit.

LPA did not observe any COVID-19 signs by the front entrance but there were signs through-out the facility. The Administrator was reminded to post COVID-19 signs by the front entrance as well.

LPA toured facility and grounds. No accessible bodies of water or fire safety hazards observed. Infection control practices are reviewed: entry procedures, staff training and policies, resident and staff daily monitoring records, containment strategies (facility will convert one bathroom for COVID-19 purposes if needed), there are 3 semi-private bedrooms in the facility; PPE supply and the environmental cleaning supply are adequate, bathrooms are equipped with soap and paper towels, and hand washing instruction is posted in the hallway and LPA recommend to post it by the hand washing stations as well. Trash cans are observed to have foot operated lids.

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

LPA Han requested for the following document to be submitted by 9/29/2021:
- Updated Emergency Disaster Plan LIC610E

No deficiency cited today. This report is reviewed and discussed with the Administrator and a copy is provided.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:

DATE: 09/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2021
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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