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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385600125
Report Date: 09/22/2022
Date Signed: 09/23/2022 08:50:09 AM


Document Has Been Signed on 09/23/2022 08:50 AM - 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: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: 132DATE:
09/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Asst. Administrator and Resident Service DirectorTIME COMPLETED:
04:30 PM
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On 9/22/2022, Licensing Program Analyst(LPA) Murial Han conducted an unannounced annual inspection. LPA observed COVID-19 signs posted by the entrance. LPA was greeted the assistant administrator, Adrienne Fair and the resident service director, Elizabeth Wyma-Hughes. 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 and hand-washing instructions signs are observed to be posted through-out the facility; garbage cans are observed to be foot operated; hand sanitizers are observed at varies locations. Main PPE supplies are stored in the maintenance shop and it is being managed by the housekeeping supervisor who conducts weekly inventory checks and order supplies accordingly. In addition to the maintenance shop, LPA observed PPE supplies stored in the medication room and the storage room on the 3rd floor where all staff has access to.

All residents are being screened for COVID-19 every shift and staff are being screened via Accusheild when they enter the facility. The facility conducted their 3rd booster clinic this week for residents and staff. The facility continued weekly testing for staff as they returned from their day off.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:
DATE: 09/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/22/2022
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
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: RHODA GOLDMAN PLAZA
FACILITY NUMBER: 385600125
VISIT DATE: 09/22/2022
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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.

No deficiency cited today.

This report is reviewed and discussed with the resident service director and the assistant administrator.

A copy is provided.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2022
LIC809 (FAS) - (06/04)
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