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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385600419
Report Date: 07/30/2021
Date Signed: 07/30/2021 02:10:22 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 4FACILITY NUMBER:
385600419
ADMINISTRATOR:FAROL, FERNANDFACILITY TYPE:
740
ADDRESS:475 EUCALYPTUS DRIVETELEPHONE:
(415) 564-6318
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94132
CAPACITY:10CENSUS: 4DATE:
07/30/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Caregiver, Rosalinda SubidaTIME COMPLETED:
11:25 AM
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On 7/30/2021, Licensing Program Analyst(LPA) Murial Han conducted an unannounced annual inspection. LPA observed COVID-19 signs posted inside by the entrance. LPA was greeted by caregiver, Rosalinda Subida who called the Administrator, Fernand Farol informing him of today's visit. LPA explained the purpose of the visit to the Administrator and the caregiver. 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, PPE supply and the environmental cleaning supply are adequate; bathrooms are equipped with soap and paper towels, hand washing instruction is posted by the hand washing stations, donning and doffing signs are posted throughout facility. Trash cans are observed to have foot operated lids. All beds are 6" apart from each other.

Medications, toxins and sharps are stored appropriately and inaccessible to clients, 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 3 residents (one resident went to Dialysis), and 1 staff member present during the inspection.

LPA suggested all PPE supplies to be stored in central location.

No deficiency cited today.

This report is reviewed, and discussed with the caregiver, Rosalinda Subida and the Administrator who was on the phone. A copy will be emailed to the Administrator.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:

DATE: 07/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2021
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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