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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385600417
Report Date: 10/26/2022
Date Signed: 10/26/2022 06:36:51 PM


Document Has Been Signed on 10/26/2022 06:36 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
SF COASTAL AC/SC, 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:
10/26/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Rosema CaspillanTIME COMPLETED:
11:15 AM
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On 10/26/2022, 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 caregiver, Rosema Caspillan. LPA explained the purpose of the visit and LPA was screened at the front entrance.

LPA toured facility and grounds. This is a single level facility. The facility appeared clean and tidy. The living room and dining room are spacious, and comfortable. 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 is 5 bedrooms at the facility- 4 privates and 1 shared (beds are observed to be 6" apart). PPE supply and the environmental cleaning supply are adequate; bathrooms are equipped with soap, 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 as well as the trash can in one of the bathrooms. LPA recommended to replace the trash can in the 2nd bathroom with a lid.

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, and 2 staff members present during the inspection.

No deficiency cited today. This report is reviewed and discussed with the caregiver and a copy is provided.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:
DATE: 10/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/26/2022
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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