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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385600385
Report Date: 06/14/2023
Date Signed: 06/14/2023 10:37:58 AM


Document Has Been Signed on 06/14/2023 10:37 AM - 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: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:
06/14/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Caregiver, Juanita SalviejoTIME COMPLETED:
10:45 AM
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On 6/14/2023, Licensing Program Analysts (LPAs) Murial Han and Komal Charitra conducted an unannounced plan of correction visit.

On 6/2/2023, LPA Charitra conducted a health and safety case management visit and observed toxins, chemicals, and sharps to be unlocked and accessible to residents. In addition, detergent and cleaning solution in the laundry room were observed to be unlocked.

During today's visit, LPA Han observed sharps, toxins, chemicals, detergent and cleaning solutions were locked, however, they were locked with a white plastic cabinet slide lock that can be removed without a key which is accessible to residents.

Due to the above observation and deficiency not being corrected, a civil penalty is being assessed in the amount of $100 a day from 6/4/2023 through 6/14/2023 and will continue to accrue until corrected.

A total civil penalty of $1,100.00 is being assessed.

Report is reviewed with caregiver, Juanita and administrator William over the phone.

A copy of this report is provided.

SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:
DATE: 06/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/14/2023
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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