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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385600399
Report Date: 09/18/2024
Date Signed: 09/18/2024 11:47:14 AM

Document Has Been Signed on 09/18/2024 11:47 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:SAN FRANCISCO RCFEFACILITY NUMBER:
385600399
ADMINISTRATOR/
DIRECTOR:		CHARISSE LIFACILITY TYPE:
740
ADDRESS:887 POTRERO AVENUETELEPHONE:
(628) 206-6402
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94110
CAPACITY: 59CENSUS: 42DATE:
09/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:46 AM
MET WITH:Calvin Latimore & Charisse LiTIME VISIT/
INSPECTION COMPLETED:
12:00 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 9/18/2024, LPA Grace Donato & Sam Yi made an unannounced annual visit to the facility. LPA met with Administrators Calvin Latimore & Charisse Li. LPAs explained the purpose of the visit.

LPA toured the facility including sample resident rooms, common areas & laundry rooms, bathrooms, and shower rooms. The indoor and outdoor passageways were free of obstruction. LPA observed some residents were in a common room watching tv. Facility has sprinklers and fire extinguishers are up to date. Hot water was also tested in the bathrooms and the temperature was 108 deg F. The residents have adequate amount of linens in their bedrooms. All personal belongings are intact. Resident bedrooms and bathrooms were observed to be in good repair. Bathrooms and shower rooms are equipped with grab bars and non-skid floors. Food is served from the main hospital’s kitchen and brought to the facility in a food warmer cart. Evacuation chair will be mounted in the stairwell. Emergency drills are up to date.

Five resident records and five staff records were reviewed. Resident records are updated, complete and signed. Staff records are complete, with training logs. Medication review was done, and all medications are accounted for, and centrally stored medication records are updated.

LPAs received the following documents: LIC500 Personnel Report, Liability insurance.

No deficiencies are cited at this time. Report is reviewed and a copy is provided.
SUPERVISORS NAME: Andrea Medlin
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE: DATE: 09/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/18/2024
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 1