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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 389210022
Report Date: 02/17/2022
Date Signed: 02/17/2022 10:54:10 AM

Document Has Been Signed on 02/17/2022 10:54 AM - 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:BRODERICK STREET ADULT RESIDENTIAL FACILITYFACILITY NUMBER:
389210022
ADMINISTRATOR:KRISTIN CHUNFACILITY TYPE:
735
ADDRESS:1421 BRODERICK STREETTELEPHONE:
(415) 292-1760
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94115
CAPACITY: 33CENSUS: 31DATE:
02/17/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Administrator, Kristin ChunTIME COMPLETED:
11:00 AM
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On 2/17/2022, Licensing Program Analyst (LPA), Murial Han conducted an unannounced Health and Welfare Checks of the residents as there is no heat at the facility due to gas pipe leakages. The facility has been working with contractors and rooter plumbing company since the problem was identified. PG&E has turned off the gas until the repair is completed and the facility passes the final inspection.

During today's visit, LPA Han met with the Administrator, interviewed the residents, conducted tour of the facility, interviewed facility staff and took temperature of varies locations thought-out the facility.

According to the Administrator, the facility has provided different interventions to ensure the residents are not being affected due to lack of heat such as providing extra blankets to the residents at night, encouraging residents to wear extra clothes during the day, monitoring the residents more frequently during night, closing the windows, and doors, monitoring the temperature within the facility, and arranging residents to have hot showers at a different location. In addition, the Administrator will continue to seek for other heating devices that are safe for the residents to use.

LPA Han interviewed 5 residents and all of them reported that they are aware of the heating situation and some of them stated that they hope it will be fix soon. All the residents stated that they are doing fine at night and they are not cold. They either wear extra clothes and/or facility staff offer them extra blankets/comforters. During the tour, LPA observed extra blankets on the resident's beds.

LPA Han took temperatures of the 8 resident's rooms and they were measured at 63 degrees - 67 degrees Fahrenheit (F). LPA Han also took temperature of the common areas such as the community rooms, the dining room, the 1st floor and the 2nd floor hallways and they were measured at 67 degrees - 69 degrees F.
SUPERVISORS NAME: Julio Montes
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE: DATE: 02/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/17/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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: BRODERICK STREET ADULT RESIDENTIAL FACILITY
FACILITY NUMBER: 389210022
VISIT DATE: 02/17/2022
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LPA Han interviewed 4 facility staff who stated that they are aware of the heating situation and they are doing fine but they also hope it will be fixed soon. In regards to residents, they are monitoring the residents more frequently, encouraging them to wear extra clothes and providing them with extra blankets.

LPA Han interviewed the designated driver who drives the residents for their showers and he/she reported that in the beginning the residents did not like it as their routine was interrupted but they actually enjoy it and they look forward to it.

LPA Han interviewed the head chef who stated that the facility is making changes to the existing menu to meet the resident's needs and the facility has purchased several portable grills for meal preparation.

After the inspection, no deficiency cited today.

This report is reviewed and discussed with the Administrator, Kristin Chun.
SUPERVISORS NAME: Julio Montes
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:

DATE: 02/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2022
LIC809 (FAS) - (06/04)
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