385601117-2-10-2022-14-AS-MHAN-CBHS4C-20220210123230

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 385601117
Report Date: 02/10/2022
Date Signed: 02/10/2022 12:32:41 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:	GOOD SHEPHERD OF SAN FRANCISO		FACILITY NUMBER:	385601117
ADMINISTRATOR:	CASTRO, MERDITH		FACILITY TYPE:	740
ADDRESS:	659 45TH AVE		TELEPHONE:	(415) 571-8531
CITY:	SAN FRANCISCO	STATE: CA	ZIP CODE:	94121
CAPACITY:	14	CENSUS: 8	DATE:	02/10/2022
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Staff, Maria Jo-an Gemina Arceo and Administrator, Merdith Castro		TIME COMPLETED:	12:40 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 2/10/22 at 10AM, Licensing Program Analyst (LPA), Murial Han met with the House Manager, Gem Arceo to conduct an unannounced Pre-Licensing inspection for change of ownership. LPA Han was properly screened by the Staff at the entry and LPA observed COVID-19 signs posted by the front entry and through-out the facility. The Administrator, Merdith Castro arrived after the tour and assisted with the rest of the inspection. LPA observed the indoor and the outdoor passageways are free of obstruction. The House Manager provided a tour of the facility. There are 4 bedrooms on the 1st floor and 4 bedrooms on the 2nd floor. There are 8 residents are the facility and 2 at the hospital. There are 4 facility staff present during the inspection. The client's rooms, the living room, the kitchen, the shower room, the bathrooms and the dining room are well maintained and appeared to be cleaned. The overall facility temperature was measured at 73 degrees Fahrenheit (F) and the hot water temperature was measured at 111 degrees F. The laundry room is cleaned and the chemicals are locked. The medication storage is locked and inaccessible to the residents. The Carbon Monoxide detectors are present and properly operated. The first aide kit is inspected and equipped. Food supplies are observed to be adequate with 7 days of non-perishable foods. The refrigerator temperature is measured at 40 degrees F and the freezer is measured at 0 degree F. The upstairs and downstairs bathrooms are cleaned, equipped with soap and paper towels and hand-washing signs are posted. The upstairs bathroom has a stockroom to store each individual resident's hygiene and shower supplies. The hygiene and shower supplies are placed in an individual basket with the resident's name on it. All the sharps in the kitchen are observed to be locked. The cook wares, the utensils and the dishes are adequate and cleaned.

SUPERVISOR'S NAME: Julio Montes	TELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 02/10/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2022

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: GOOD SHEPHERD OF SAN FRANCISO	FACILITY NUMBER: 385601117
	VISIT DATE: 02/10/2022

NARRATIVE

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LPA observed the following postings, Resident Rights, Ombudsman Poster, House Rules, Licensing Complaint Poster, the Resident Council Rights, Breakfast Time and Shower Schedule for the residents. In addition, there are COVID-19 signs and hand-washing instructions observed through-out the facility and in the bathrooms.

PPE supplies are adequate; some are stored in the downstairs stockroom with other supplies such as attends, gloves, cleaning supplies and the rest of the PPE supplies are stored in the upstairs office. The facility continues to conducted COVID-19 screening for all residents twice a day and staff as well.

There were no objects obstructing the emergency water, electricity and gas shut-off stations (instructions are labeled).

Facility sketch accurately reflects the floor plan.

Comp III orientation was given to the Administrator, Merdith Castro and House Manager, Gem Arceo on 2/10/22

Pre-Licensing is now complete. Immediate Licensure is recommended pending final approval from the Central Applications Bureau.

Exit interview conducted with the Administrator, Meredith Castro and House Manager, Gem Arceo. A copy of the report is provided.

SUPERVISOR'S NAME: Julio Montes	TELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 02/10/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2022

LIC809 (FAS) - (06/04)

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