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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385600019
Report Date: 11/08/2021
Date Signed: 11/08/2021 01:48:16 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:PROVIDENCE PLACEFACILITY NUMBER:
385600019
ADMINISTRATOR:KNOP, GALINAFACILITY TYPE:
740
ADDRESS:2456 GEARY BLVD.TELEPHONE:
(415) 359-9700
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94115
CAPACITY:34CENSUS: 23DATE:
11/08/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Health and Wellnes Director, Catherine VillegasTIME COMPLETED:
12:15 PM
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On 11/8/2021, Licensing Program Analyst(LPA) Murial Han conducted an unannounced annual inspection. LPA observed COVID-19 signs posted by the entrance. LPA was greeted by caregiver, Joy Bautista then the Health and Wellness Director, Catherine Villegas arrived at the facility and assisted with the annual inspection.. 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 (residents are being screened 3 time per day), containment strategies (facility has designated rooms for isolation and quarantine purposes). PPE supply and the environmental cleaning supply are adequate (facility cleans and disinfects high touched surfaces 2x/shift and floor daily), bathrooms are equipped with hand washing instructions, liquid soap and paper towels. Bathroom Trash cans are with foot operated lids; LPA Han recommended to have foot operated lid or trash can with lid in the kitchen as well. Staff is observed to be wearing face covering and staff will continue to remind residents to wear face covering. The beds in the semi-private rooms are 6" apart from each other. COVID-19 signs, cough etiquette signs and hand washing signs are observed through-out the facility. LPA Han recommended to post hand washing sign by the kitchen sink.

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

During today's inspection, LPA Han requested for the following document to be submitted to the Regional Office by 11/10/2021
- Updated Emergency Disaster Plan LIC 610E

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

DATE: 11/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2021
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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