<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385600270
Report Date: 10/10/2022
Date Signed: 10/12/2022 02:18:45 PM


Document Has Been Signed on 10/12/2022 02:18 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:ALMA VIA OF SAN FRANCISCOFACILITY NUMBER:
385600270
ADMINISTRATOR:ALAN FOXFACILITY TYPE:
740
ADDRESS:ONE THOMAS MORE WAYTELEPHONE:
(415) 337-1339
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94132
CAPACITY:175CENSUS: 118DATE:
10/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Administrator, Alan FoxTIME COMPLETED:
12:15 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 10/10/2022, Licensing Program Analyst(LPA) Murial Han conducted an unannounced annual inspection. LPA Han was properly screened for COVID-19 by the receptionist at front entrance. After the screening, LPA was greeted by the Administrator, Alan Fox and LPA explained the purpose of the visit.

LPA reviewed the following documents: daily monitoring and screening documents for residents, staff and visitors, and Infection Control training records.

LPA toured the facility and observed COVID-19 signs posted throughout the facility. The public bathrooms on 1st floor have hand-washing signs posted, foot operated lids, equipped with motion censor paper towel and liquid soap dispensers. There are hand sanitizer dispensers installed throughout the facility.

LPA toured 3 memory care neighborhoods and observed chemicals are locked in a designated room, each memory care neighborhood and its own medication room and were observed to be locked, the trash can have foot operated lids, and dining room tables were 6" apart.

Facility has dedicated one apartment for PPE and cleaning supplies storage for at least 30 days. Inside this apartment, LPA observed donning and doffing signs, isolation carts, inventory sign-out sheets and cleaning supplies. According to the administrator, facility conducts inventory orders on a monthly basis.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:
DATE: 10/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/10/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


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: ALMA VIA OF SAN FRANCISCO
FACILITY NUMBER: 385600270
VISIT DATE: 10/10/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
LPA toured the kitchen and observed 2 day perishable and 7 day non-perishable. The kitchen appeared to be cleaned and tidy. there are 3 hand washing sinks with hand washing instruction posted. LPA observed the temperature for the refrigerator was measured at 38 degrees Fahrenheit (F) and the freezer was measured at -10 degrees F.

LPA toured the 2nd floor nursing station in a locked room and observed First Aid Kits were equipped and the medication carts were locked.

Overall, the facility appeared to be cleaned and tidy, toxins and sharps are stored appropriately and inaccessible to residents. A comfortable temperature is maintained, lighting is sufficient for comfort and safety.

During today's visit- LPA requested for a copy of the LIC610E (Emergency Disaster Plan) to be submitted to CCL by 10/13/2022.

No deficiency cited today. This report is reviewed and discussed with the Administrator.

A copy of this report is provided.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:

DATE: 10/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2