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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 410500325
Report Date: 01/03/2023
Date Signed: 01/19/2023 01:09:19 PM

Document Has Been Signed on 01/19/2023 01:09 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:FHAR - HORIZON HOMEFACILITY NUMBER:
410500325
ADMINISTRATOR:MCKIBBEN, LISAFACILITY TYPE:
735
ADDRESS:901 NORTH ROADTELEPHONE:
(650) 593-2669
CITY:BELMONTSTATE: CAZIP CODE:
94002
CAPACITY: 8CENSUS: 0DATE:
01/03/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:19 PM
MET WITH:Administrator, Lisa McKibbenTIME COMPLETED:
01:17 PM
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On January 19, 2023, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced annual infection control inspection. Upon arrival, LPA observed the COVID-19 signage posted at the front entrance. LPA met with Administrator, Lisa McKibben and explained the purpose of the visit. Administrator was able to provide LPA with screening log documentation for visitors, clients, and staff.

LPA toured the facility and grounds. No accessible bodies of water or fire safety hazards observed. This is a 4 bedroom and 3 bath facility with an office room. LPA toured and observed all 4 bedrooms to be client rooms with beds 6ft apart from each other or 3ft head-to-toe. All 3 bathrooms were observed to be equipped with liquid soap, paper towels, and hand-washing signs. LPA advised administrator to ensure all bathrooms have a trash can with a fitted lid. During the visit, there were no clients present. According to the administrator, all 7 clients were at their day program. LPA observed living room and dining room to be clean and free from any tripping hazards. A comfortable temperature is maintained and lighting is sufficient for comfort. LPA toured the kitchen and observed 2 day perishable and 7 day non-perishable.

Medications and toxins were locked and stored appropriately in the office room. Extra food supply was present. Washer and dryer was observed to be in good repair. COVID-19 signage was posted throughout the facility. Overall the facility was clean and in good repair.
Infection control practices are observed: entry procedures, daily monitoring log for staff, clients, and visitors, 30-day PPE supply, face coverings for staff, containment strategies, staff training and policies.

LPA requests the following forms to be submitted to CCLD by 1/26/2023:
-LIC308 Designation of Administrative Responsibility
-LIC500 Personnel Report
-LIC610D Emergency Disaster Plan
-Administrator Certificate

No citations will be issued during this visit. Report is reviewed with the Administrator and a copy is provided.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE: DATE: 01/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/03/2023
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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