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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385600401
Report Date: 04/05/2022
Date Signed: 04/05/2022 05:07:19 PM


Document Has Been Signed on 04/05/2022 05:07 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
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066



FACILITY NAME:BYXBEE HOMEFACILITY NUMBER:
385600401
ADMINISTRATOR:KRISTINA NICOLE, ATENDIDOFACILITY TYPE:
740
ADDRESS:383 BYXBEE STREETTELEPHONE:
(415) 586-4663
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94132
CAPACITY:4CENSUS: 3DATE:
04/05/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Administrator, Kristina Nicole AtendidoTIME COMPLETED:
01:10 PM
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On 4/5/2022, Licensing Program Analyst(LPA) Murial Han conducted an unannounced annual inspection. LPA observed COVID-19 signs posted by the entrance. LPA was greeted by the administrator, Kristina Nicole Atendido. LPA explained the purpose of the visit and LPA was screened at the front entrance.

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 3 male residents at the facility and all the rooms are private. PPE supply and the environmental cleaning supply are adequate, bathrooms are equipped with liquid soap and paper towels, and hand washing instruction is posted by the hand washing stations. Trash cans are observed to be foot operated. Facility has set up ready-to-go isolation cart filled with PPE supplies for isolation and/or quarantine purposes.

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 kit is inspected and complete.

During today's inspection, LPA Han requested for the following document to be submitted to the Regional Office by 4/8/2022.
- Updated Emergency Disaster Plan LIC610E; Administrator Certification, LIC 308 Designation of Responsibility, and LIC 500

No deficiency cited today. This report is reviewed and discussed with the administrator. A copy is provided.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:
DATE: 04/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/05/2022
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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