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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385600350
Report Date: 01/24/2023
Date Signed: 01/24/2023 01:41:31 PM

Document Has Been Signed on 01/24/2023 01:41 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:GONZALES HOMEFACILITY NUMBER:
385600350
ADMINISTRATOR:GONZALES, ROGELIO & PROSPEFACILITY TYPE:
740
ADDRESS:2237 NORIEGA STREETTELEPHONE:
(415) 242-0848
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94122
CAPACITY: 6CENSUS: 4DATE:
01/24/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Caregiver, Rosario CunninghamTIME COMPLETED:
10:40 AM
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On 1/24/2023, Licensing Program Analyst(LPA) Murial Han conducted an unannounced annual inspection. LPA observed COVID-19 signs posted by the entrance. LPA was greeted by staff, Rosario Cunningham. LPA explained the purpose of the visit and staff contacted the administrator informing of today's inspection.

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. there are 4 residents at the facility (2 females and 2 males). Facility has 3 rooms (2 privates and 1 shared) upstairs occupied by 3 residents and 1 private room downstairs occupied. The beds in the shared bedroom observed to be 6" apart. PPE supply and the environmental cleaning supply are adequate, bathrooms are equipped with liquid soap and paper towels, hand washing instruction is posted by the hand washing stations. Trash can in the kitchen observed with closed foot operated lid.

Facility observed to be cleaned, and tidy; a comfortable temperature is maintained, and lighting is sufficient.

Medications, toxins and sharps are stored appropriately and inaccessible to residents. Food supply was checked and observed to be sufficient. First-aid kit is inspected and complete. There are 4 residents, and 2 staff members present during the inspection.

During today's inspection, LPA Han requested for the following document to be submitted to the Regional Office by 1/26/2023:
- Updated Emergency Disaster Plan LIC610E
- LIC500
- A copy of administrator certification

No deficiency cited today; this report is reviewed and discussed with caregiver, Rosario Cunningham and a copy is provided.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE: DATE: 01/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/24/2023
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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