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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 380540169
Report Date: 10/01/2023
Date Signed: 10/01/2023 03:20:23 PM

Document Has Been Signed on 10/01/2023 03:20 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:FLOR'S RESIDENTIAL CARE HOMEFACILITY NUMBER:
380540169
ADMINISTRATOR:BAUTISTA, FLOR E.FACILITY TYPE:
735
ADDRESS:301 EDINBURGH STREETTELEPHONE:
(415) 584-6252
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94112
CAPACITY: 6CENSUS: 6DATE:
10/01/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH: Perla RemetioTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to conduct a Required - 1 Year visit on 10/1/23 at 2:00PM. LPA met with Perla Remetio, Caregiver and stated the purpose of the visit. Caregiver is fingerprint cleared and associated to the facility. The facility is licensed for a capacity of 6 ambulatory residents.

The Administrator Certificate was observed for Flor Bautista which expires 11/5/23.

LPA observed 5 residents participating in individual activities and 1 was out in the community during this visit. LPA toured and inspected the physical plant inside and outside to ensure there are no safety hazards to residents.

LPA observed 2-day perishables and 7-day non-perishables. The temperature inside the facility was observed to be at 73*F which is within the required range of 68-85*F. The hot water temperature was measured at 106.2*F which is within the required range of 105-120*F. LPA observed fire extinguisher(s), pull alarm system, smoke and carbon monoxide detectors in the facility. LPA observed the centrally stored medications area to be locked and inaccessible to residents. The first aid kit contained the required items such as sterile dressings, bandages, adhesive tape, scissors, tweezers, thermometers, antiseptic solution and guide.

LPA observed 1 staff files and 2 resident files and conducted interviews of staff and residents during this visit.

Upon a file review the following items were discussed to be submitted with any changes annually:
Infection Control Plan, Designation of Facility Responsibility (LIC308), Personnel Report (LIC500) to include the Administrator presence in the facility, Administrator Certificate-Updated, Affidavit Regarding Client/Resident Cash Resources (LIC400), Surety Bond (LIC402), Emergency Disaster Plan (LIC610E) .

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 6, no deficiencies are being cited. An exit interview was conducted, a copy of the report was given.
SUPERVISORS NAME: Victoria Brown
LICENSING EVALUATOR NAME: Victoria Brown
LICENSING EVALUATOR SIGNATURE: DATE: 10/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/01/2023
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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