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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385600394
Report Date: 07/09/2024
Date Signed: 07/09/2024 03:40:43 PM


Document Has Been Signed on 07/09/2024 03:40 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066



FACILITY NAME:FOOK HONG SF CARE HOME, INC.FACILITY NUMBER:
385600394
ADMINISTRATOR:LEEWONG, SAU TING JOSEPHINFACILITY TYPE:
740
ADDRESS:5735 MISSION STREETTELEPHONE:
(415) 533-0541
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94112
CAPACITY:40CENSUS: 40DATE:
07/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Licensee/Administrator - Josephine Lee WongTIME COMPLETED:
03:45 PM
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On 07/09/2024, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced annual inspection visit. LPA met with licensee/administrator Josephine Lee Wong and explained the purpose of today's visit. There are multiple staff and all 40 residents are present.

LPA was allowed entry into the facility. This is a multilevel facility with a waiver for five hospice residents of which three residents are on hospice at time of this visit. Residents reside on the upper two floors while the entire ground floor is the communal space, dining room, kitchen, and lobby of the facility. The physical plant was toured inside and outside to ensure the safety of the residents. LPA observed the facility kitchen which is clean and observed appliances are in good repair. Knives are stored and locked in the kitchen behind a locking main door. Medications are observed to be locked in a medication room/office on the ground floor. Perishable and non-perishable food items are observed as in place and plentiful. First aid kit is observed as complete with required items. LPA observed that there are multiple fire extinguishers through out the facility in place inspected 07/03/24, smoke detector/carbon monoxide detectors are observed in place through out the facility, and central heating/cooling system. The facility is also fully equipped with fire sprinklers. PPE and additional staff supplies are observed in storage areas on the ground floor. Laundry area is observed as fully operational located behind locked doors on the ground floor. Emergency exit routes are observed inside and outside to be free and clear of obstructions. Last emergency/disaster drill was conducted on 06/17/2024. Water temperature was measured at 115F on both the first floor and second floor in resident common full bathrooms. Shower floor use non-skid mat when shower is in use. Both resident levels of the facility have three common full bathrooms. Some of the larger shared rooms at the end of each floor have full bathrooms as well. LPA observed resident rooms at random and all appeared clean, free of odors, and contained all the required furniture per regulatory recommendations. Resident linen supplies are observed as in place as well. Resident incontinence supplies are stored in each residents room for their use. Facility toxic and cleaning supplies are in locked closets on the ground floor.

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SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8865
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:
DATE: 07/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/09/2024
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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: FOOK HONG SF CARE HOME, INC.
FACILITY NUMBER: 385600394
VISIT DATE: 07/09/2024
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LPA reviewed 4 resident files and also reviewed 4 staff files on this day. Per resident files reviewed they are current. Per staff files reviewed all files were current with training and CPR/First Aid. P&I is not handled by the facility. Client medications are inspected and are current including facility medication administration records. Administrator certificate is observed as current expiring on 11/24/2025. Infection control plan is current as of 07/01/2023. As of today's inspection the infection control plan is current with no changes.
No citations issued on this day. Report is reviewed with Josephine Lee Wong and a copy is provided.
SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8865
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:

DATE: 07/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2024
LIC809 (FAS) - (06/04)
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