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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385600359
Report Date: 08/17/2022
Date Signed: 08/17/2022 01:50:16 PM


Document Has Been Signed on 08/17/2022 01:50 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:CARLISLE, THEFACILITY NUMBER:
385600359
ADMINISTRATOR:FOX, ALANFACILITY TYPE:
740
ADDRESS:1450 POST STTELEPHONE:
(415) 929-0200
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94109
CAPACITY:130CENSUS: 81DATE:
08/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Administrator, Stephanie SchmautzTIME COMPLETED:
12:10 PM
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On 8/17/2022, Licensing Program Analyst(LPA) Murial Han conducted an unannounced annual inspection. LPA observed COVID-19 signs posted by the receptionist area. LPA was properly screened at the main entry and greeted by the administrator. 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- staff, visitors and residents are screen at the main entry; staff training includes- Infection Control, Proper PPE Procedures, PPE Skill Demonstration, Hand Hygiene, etc; resident and staff daily monitoring/screening records and containment strategies.

During tour, LPA observed an isolation room with isolation cart including appropriate PPE supplies and donning and doffing instruction set-up by the door, closed lid garbage can, and isolation sign posted on the door.

LPA also observed residents and staff wearing face covering during activity and in the common areas. Facility has a fitness room and the excise equipment has a sign indicating whether it has been sanitized or not. If not, staff does all the sanitization of the equipment after each use.

PPE supply and 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 lids.

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

No deficiency cite today.

This report is reviewed and discussed with the 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: 08/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/17/2022
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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