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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385600358
Report Date: 08/31/2022
Date Signed: 08/31/2022 03:50:41 PM


Document Has Been Signed on 08/31/2022 03:50 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:DAMENIK'S HOMEFACILITY NUMBER:
385600358
ADMINISTRATOR:MONTILLA, DANILO F.FACILITY TYPE:
740
ADDRESS:331 30TH AVENUETELEPHONE:
(415) 379-9051
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94121
CAPACITY:12CENSUS: 11DATE:
08/31/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Lead Staff, MaTheresa AldayTIME COMPLETED:
02:20 PM
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On 8/31/22, Licensing Program Analyst(LPA) Murial Han conducted an unannounced annual inspection. LPA observed COVID-19 signs posted by the entrance and LPA was properly screened. LPA was greeted by the Lead Staff, MaTheresa Alday. LPA explained the purpose of the visit.

LPA toured facility and grounds. No accessible bodies of water or fire safety hazards observed. Infection control practices are reviewed: entry procedures, resident and staff daily monitoring records, containment strategies. there are 11 residents at the facility (4 downstairs and 7 upstairs). There are 4 shared rooms at the facility, and the beds are observed to be 6" apart with a privacy curtain in between each bed. 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 cans are observed to have foot operated lid.

Medications, toxins and sharps are stored appropriately and inaccessible to resident, a comfortable temperature is maintained, lighting is sufficient for comfort and safety and food supply was checked and observed to be sufficient. First-aid kit is inspected and complete.

During today's inspection, LPA requested for a copy of the facility's infection control plan to be submitted to CCL by September 2, 2022.

No deficiency cited today.

This report is reviewed and discussed with the lead staff.

A copy is provided.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:
DATE: 08/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/31/2022
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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