385600377-12-21-2021-14-AS-DTOA-C9X2MY-20211221163152

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 385600377
Report Date: 12/21/2021
Date Signed: 12/21/2021 04:34:33 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME:	MERCED GIRARD RESIDENTIAL CARE FACILITY		FACILITY NUMBER:	385600377
ADMINISTRATOR:	WU, JAMES O.D		FACILITY TYPE:	740
ADDRESS:	129 GIRARD STREET		TELEPHONE:	(415) 467-8900
CITY:	SAN FRANCISCO	STATE: CA	ZIP CODE:	94134
CAPACITY:	42	CENSUS: 35	DATE:	12/21/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:20 PM
MET WITH:	Michael Lee, Administrator		TIME COMPLETED:	03:20 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	Licensing Program Analyst (LPA) Tobola arrived unannounced to conduct a Required - 1 Year inspection and met with Administrator, Michael Lee (ML). The annual inspection is focused on the Infection Control procedures and practices of this Residential Care Facility for Elderly. Facility provides care for 35 residents, 4 of which are on after-hour nursing services and some of which with a diagnosis of dementia. LPA toured facility and grounds with Administrator and observed COVID-19 precaution signs posted in common areas to promote hand washing and physical distancing. LPA was screened for COVID-19 symptoms upon entrance to this facility. Visitors are said to be screened for COVID-19 symptoms (including temperature check) upon arrival to the facility. Infection control practices are present: entry procedures, face coverings, daily monitoring and temperatures checked for staff and residents based on daily observation, and a 30-day PPE supply. Staff follow indoor visitation requirement of verifying and tracking COVID-19 vaccination or verify non-essential visitors have proof of a negative COVID-19 test within 72 hours and implement visitation protocols to mitigate the spread of COVID-19. Staff clean and disinfect the facility multiple times daily. Administrator stated high touched surface areas are disinfected after each use, such as the bathroom and kitchen area. Resident rooms and common areas have disinfecting wipes and hand sanitizer available. Bathrooms are equipped with liquid soap, paper towels and touch free operated garbage cans. Staff understand hand sanitizer should not be placed in the rooms of residents who lack hazard awareness and impulse control. Facility submitted a mitigation program plan, and plan has been reviewed. LPA reviewed training records and found all caregivers to have completed PPE training. In addition, all staff have current CPR & 1st Aid Training on file. Continued onto LIC809-C

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) -58-5051
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 12/21/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2021

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: MERCED GIRARD RESIDENTIAL CARE FACILITY	FACILITY NUMBER: 385600377
	VISIT DATE: 12/21/2021

NARRATIVE

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In addition, facility was found to be at a comfortable temperature with all exits free from obstruction. No accessible bodies of water or fire safety hazards observed. Fire Extinguishers were found to be last serviced and inspected in 2019. Administrator stated that fire inspection services have been contacted and fire extinguishers will be inspected within one week. Facility had originally scheduled fire extinguisher inspection in 2020 but was postponed due to an outbreak lasting months in the facility. Smoke and Carbon monoxide detectors were fully functional and last inspected on 9/24/2021. Facility elevator is inspected on a monthly basis with a last inspection completed in December 2021.

There was sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations on this day at the time of the visit. Toxins were stored in a secured maintenance closet location in the facility basement.

LPA requested the following updated documents to be submitted to CCLD by 12/28/2021:

LIC500 Personnel Report
LIC610 Emergency Disaster Plan
Control of Property
Designation of Responsibility

Exit interview conducted with Administrator, whose signature on this document confirms receipt.
Due to printer malfunction, this report was emailed to Administrator.

No deficiencies cited during this inspection.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) -58-5051
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 12/21/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2021

LIC809 (FAS) - (06/04)

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