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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385600125
Report Date: 04/04/2022
Date Signed: 04/05/2022 05:04:57 PM


Document Has Been Signed on 04/05/2022 05:04 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
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066



FACILITY NAME:RHODA GOLDMAN PLAZAFACILITY NUMBER:
385600125
ADMINISTRATOR:IRA KURTZFACILITY TYPE:
740
ADDRESS:2180 POST STREETTELEPHONE:
(415) 345-5060
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94115
CAPACITY:195CENSUS: 133DATE:
04/04/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Administrator, Ira Kurtz and Assistant administrator, Adrienne FairTIME COMPLETED:
02:30 PM
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On 4/4/22, Licensing Program Analyst(LPA) Murial Han conducted an unannounced annual inspection. LPA observed COVID-19 signs posted by the entrance. LPA was greeted the administrator, Ira Kurtz and the assistant administrator, Adrienne Fair. 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, PPE supply and the environmental cleaning supply are adequate; bathrooms are equipped with soap and paper towels; COVID-19 signs are observed to be posted through-out the facility in different languages; all the resident rooms are private; hand washing instruction is posted by the hand washing stations; garbage cans are observed to be foot operated; hand sanitizers are observed at varies locations within the facility; PPE supplies are stored at varies locations and observed to be adequate. The facility conducts inventory counts once every two weeks and order supplies according to the burn-rate calculation.

All residents are being screened for COVID-19 every shift and staff are being screened via Accusheild when they enter the facility. The facility completed its 2nd round of annual N95 fit testing for the facility staff.

Medications are locked in the medication rooms. First aide kits are observed to be equipped in the medication rooms and nursing stations. A comfortable temperature is maintained, lighting is sufficient for comfort. The high- touched areas are being cleaned and disinfected per shift.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:
DATE: 04/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/04/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: RHODA GOLDMAN PLAZA
FACILITY NUMBER: 385600125
VISIT DATE: 04/04/2022
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LPA observed COVID-19 signs in the staff lounge, and the chairs are 6" apart.

LPA requested for the following documents to be submitted to CCL by Wednesday 4/6/2022
- A copy of the current administrator certification, LIC308 Designation of Administrative Responsibility, LIC 309 Administrative Organization, and LIC 400 Affidavit Regarding Client/Resident Cash Resources

No deficiency cited today.
This report is reviewed and discussed with the administrator. A copy is provided.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:

DATE: 04/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2022
LIC809 (FAS) - (06/04)
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