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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 410504131
Report Date: 09/06/2022
Date Signed: 09/06/2022 10:35:20 AM

Document Has Been Signed on 09/06/2022 10:35 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
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:CATHOLIC CHARITIES ADULT DAY SERVICES-SAN MATEO COFACILITY NUMBER:
410504131
ADMINISTRATOR:CLEMENT-CIHAK, PATRICIAFACILITY TYPE:
775
ADDRESS:787 WALNUT STREETTELEPHONE:
(650) 592-9325
CITY:SAN CARLOSSTATE: CAZIP CODE:
94070
CAPACITY: 40CENSUS: 5DATE:
09/06/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Program Director, Carmen SantoniTIME COMPLETED:
10:45 AM
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On September 6, 2022, 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 Program Director, Carmen Santoni and explained the purpose of the visit. LPA Charitra was screened at entry point and Program Director was able to provide screening log documentation for staff, residents, and visitors.

LPA toured the facility with the Program Director, no accessible bodies of water or fire safety hazards observed. During the visit, LPA observed 5 clients and 2 staff members maintaining social distancing in the main activity room. Tables and chairs were observed to be 6ft apart. Staff were observed to be wearing a face coverings. LPA toured the kitchen and observed toxins, chemicals, and sharps stored appropriately and inaccessible to residents. Kitchen was equipped with liquid soap, paper towels, hand-washing sign and a trash can with a fitted lid. According to the Program Director, clients to not have access to the kitchen, however they are able to utilize the facility refrigerator to store their food.

Main activity room and toddler room were clean and odor-free. All rooms were clear from any tripping hazards. 30-day PPE supply was stored in the nursery room. There are 3 bathrooms in the facility; Ladies, Men's and ADA. All bathrooms were observed to be equipped with liquid soap, paper towels, hand-washing sign, grab-bars, and a trash can with a fitted lid. LPA observed the furnace room and the janitor room. According to the Program Director, clients do not have access to these rooms. There are two staff offices located on the first floor and two offices located on the second floor. A comfortable temperate is maintained. Lighting was sufficient for comfort. LPA observed the first aid kit to be completed. COVID-19 signage was observed to be posted throughout the facility.

LPA requests the following forms to be submitted to CCLD by 9/13/22:
  • LIC308 Designation of Administrative Responsibility
  • LIC500 Personnel Report
  • Administrator Certificate
  • LIC610D Emergency Disaster Plan


No citations issued during the visit. Report is reviewed with Program Director, Carmen Santoni and a copy is provided.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE: DATE: 09/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/06/2022
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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