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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385600019
Report Date: 08/11/2022
Date Signed: 08/11/2022 05:31:37 PM


Document Has Been Signed on 08/11/2022 05:31 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
SF COASTAL AC/SC, 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: 26DATE:
08/11/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:10 PM
MET WITH:Health and Wellness Director, Catherine VillegasTIME COMPLETED:
01:30 PM
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On 8/11/2022, Licensing Program Analyst(LPA) Murial Han conducted an unannounced annual inspection. LPA met with the health wellness director and explained the purpose of the visit. LPA was screened at the front entrance.

LPA toured facility and grounds. The facility appeared to be cleaned and tidy. No accessible bodies of water or fire safety hazards observed. Infection control practices are reviewed (facility continues to conduct COVID-19 testing for staff and residents every 2 weeks). LPA reviewed entry procedures, staff training and policies, resident and staff daily monitoring records, containment strategies. PPE supply and the environmental cleaning supply are adequate, bathrooms are equipped with hand washing instructions, liquid soap and paper towels. Bathroom trash cans are with foot operated lids. Staff is observed to be wearing 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.

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 adequate.

No deficiency cited.

This report is reviewed and discussed with Health and Wellness Director.

A copy is provided.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:
DATE: 08/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/11/2022
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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