<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385600385
Report Date: 09/24/2021
Date Signed: 09/24/2021 05:14:50 PM

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:CORINTHIAN GARDEN RESIDENTIAL CARE HOMEFACILITY NUMBER:
385600385
ADMINISTRATOR:ENCARNACION, WILLIAM S.FACILITY TYPE:
740
ADDRESS:170 APTOS AVENUETELEPHONE:
(415) 841-0311
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94127
CAPACITY:6CENSUS: 5DATE:
09/24/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Administrator, William EncarnacionTIME COMPLETED:
12:45 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
On 9/24/2021, Licensing Program Analyst(LPA) Murial Han conducted an unannounced annual inspection. LPA was greeted by the Administrator, William Encarnacion. LPA explained the purpose of the visit.

LPA observed some signs posted by the front door and through-out the facility. The Administrator stated that he will re-post additional COVID-19 signs by the front entry point and within the facility.

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 2 semi-private and 1 private bedrooms in the facility; PPE supply and the environmental cleaning supply are adequate, bathrooms are equipped with soap and paper towels, and hand washing instruction is posted. 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 and food supply was checked and observed to be sufficient. First-aid kits are inspected and complete.

LPA reminded the Administrator to continue with the daily temperature monitoring for the residents and staff members. LPA reviewed facility's vaccination status.

LPA Han requested for the following documents to be submitted by 9/28/2021:
- Designation of Administrative Responsibility (LIC308)
- Proof of submission for the Administrator Certification

No deficiency cited today. This report is reviewed and discussed with the Administrator and a copy is provided.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:

DATE: 09/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 3