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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 380540408
Report Date: 08/24/2021
Date Signed: 08/24/2021 08:25:20 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:JANET'S RESIDENTIAL FACILITY FOR THE ELDERLYFACILITY NUMBER:
380540408
ADMINISTRATOR:SPIRES, JANETFACILITY TYPE:
740
ADDRESS:2970 25TH AVENUETELEPHONE:
(415) 759-8137
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94132
CAPACITY:8CENSUS: 6DATE:
08/24/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Administrator, Janet SpiresTIME COMPLETED:
12:40 PM
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On 8/24/2021, Licensing Program Analyst(LPA) Murial Han conducted an unannounced annual inspection. LPA observed COVID-19 signs posted by the entrance. LPA was greeted by the Administrator, Janet Spires. LPA explained the purpose of the visit and LPA was screened at the front entrance.

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 room for isolation), PPE supply and the environmental cleaning supply are adequate; bathrooms are equipped with soap and paper towels, and hand washing instruction is posted by the hand washing stations. Signs are posted through-out the facility. Trash cans are observed to have foot operated lids. All beds are at least 6" apart from each other. Facility has designated a staff member to care for residents who are in quarantine/isolation.

Medications, toxins and sharps are stored appropriately and inaccessible to clients, 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. There are 6 residents, 2 staff members, the Administrator and the Administrator's son present during the inspection.

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: 08/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2021
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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