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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385600417
Report Date: 10/21/2021
Date Signed: 10/21/2021 04:26:48 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:QUALITY CARE HOMES, LLC 2FACILITY NUMBER:
385600417
ADMINISTRATOR:FAROL, FERNAND & VERANO, MFACILITY TYPE:
740
ADDRESS:757 - 44TH AVENUETELEPHONE:
(415) 751-5469
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94121
CAPACITY:6CENSUS: 5DATE:
10/21/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Caregiver, Rosema CaspillanTIME COMPLETED:
12:00 PM
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On 10/21/2021, 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 Caregiver in charge, Rosema Caspillan. 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 (all residents have their own private room and the facility has designated a bathroom for the resident with COVID-19 symptoms if needed), there are 5 bedrooms in the facility and 4 of them are private rooms and 1 is shared but currently there is only 1 resident occupying that room; PPE supply and the environmental cleaning supply are adequate (LPA informed the facility that the Regional Office has PPE supplies to share if needed); bathrooms are equipped with soap and paper towels, and hand washing instruction is posted by the hand washing stations. Signs are posted through-out the facility. The trash can in the kitchen has a closed lid and LPA suggested to replace the rest of the trash cans with lids as well.

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. There are 4 residents (1 went to On-Lok Adult Day Program), and 2 staff members present during the inspection.

During today's inspection, LPA Han requested for the following documents to be submitted by 1028/2021 and recommended to have additional COVID-19 signs.
- Updated Administrator Certification, LIC308, Facility Lease and Updated Emergency Disaster Plan LIC610E

No deficiency cited today. This report is reviewed and discussed with the Caregiver 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: 10/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2021
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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