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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385600277
Report Date: 04/18/2022
Date Signed: 04/18/2022 02:30:11 PM


Document Has Been Signed on 04/18/2022 02:30 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:SFAL - THE AVENUEFACILITY NUMBER:
385600277
ADMINISTRATOR:WONG, TERESAFACILITY TYPE:
740
ADDRESS:1035 VAN NESS AVENUETELEPHONE:
(415) 776-1800
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94109
CAPACITY:145CENSUS: 19DATE:
04/18/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Administrator, Teresa WongTIME COMPLETED:
12:40 PM
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On 4/18/2022, Licensing Program Analyst(LPA) Murial Han conducted an unannounced annual inspection. LPA observed COVID-19 signs posted by the entrance. LPA was greeted by administrator, Teresa Wong. 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. LPA observed COVID-19 signs through-out the facility and hand washing signs were posted by the sinks. The furniture in the resident's dining rooms was observed to be 6" apart and only one resident is assigned per table. LPA observed residents were at least 6" apart during lunch time on the 5th floor dining room. Food supply was checked and observed to be sufficient. The refrigerator temperature was measured at 35 degree Fahrenheit and freezer was measured at 0 degree Fahrenheit.

The facility has dedicated 1 room on the 8th floor for quarantine and isolation purposes and the room next door for donning and doffing with a foot operated garbage can inside the room. In addition, the facility has dedicated another private room on the 8th for family to stay during their visit if needed.

LPA observed PPE and cleaning supply to be sufficient and the administrator conducts burn rate calculation and places order accordingly.

Medications, toxins and sharps are stored appropriately and inaccessible to resident, a comfortable temperature is maintained, lighting is sufficient for comfort. 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 4/22/2022:

- Updated Emergency Disaster Plan LIC610E , a copy of the administrator certification, LIC 308 (Designation of responsibility)

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: 04/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/18/2022
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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