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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 410507269
Report Date: 03/09/2022
Date Signed: 03/16/2022 03:01:19 PM

Document Has Been Signed on 03/16/2022 03:01 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
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:CASSIA HOUSEFACILITY NUMBER:
410507269
ADMINISTRATOR:MARY BETH SANDOVALFACILITY TYPE:
735
ADDRESS:420 CASSIA STREETTELEPHONE:
(650) 363-8125
CITY:REDWOOD CITYSTATE: CAZIP CODE:
94063
CAPACITY: 14CENSUS: DATE:
03/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Administrator, Marybeth SandovalTIME COMPLETED:
12:15 PM
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On March 9, 2022, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced annual infection control inspection. Upon arrival, LPA did not observe signage on the front door. LPA was greeted by the Administrator, Mary Beth Sandoval and explained the purpose of the visit. LPA was screened at the entry point and the administrator was able to provide screening log documentation for residents, visitors, and staff. LPA advised Administrator to post COVID signage (masking, symptoms, social distancing, cough etiquette) signage on the front door.

LPA toured facility and grounds. No accessible bodies of water or fire safety hazards observed. Infection control practices are present: entry procedures, daily monitoring for residents and staff, and 30-day PPE supply. Bathrooms are equipped liquid soap and paper towels. However, LPA advised Administrator that the paper towels should have a dispenser and that the trash cans should be covered with lids. LPA advised Administrator to not keep any bar soaps in the bathrooms and that hand-towels should not be present in the bathrooms or the kitchen.

LPA observed COVID signs posted throughout the facility. LPA observed 7 bedrooms in the facility, all shared rooms with the beds either 6 feet apart or 3 feet apart from head-to-toe. LPA observed 2 day perishable and 7 day non-perishable present.

Medications, toxins and sharps are stored appropriately and inaccessible to residents, and a comfortable temperature is maintained, lighting is sufficient for comfort. First aid kit was observed to be completed.

The following updated forms are requested to be submitted to CCLD by 3/16/2022:
-LIC308 Designation of Administrative Organization
-LIC500 Personnel Report
-LIC400 Resident Cash Resources
-Administrator Certificate
-LIC610D Emergency Disaster Plan

Report is reviewed with Administrator, Marybeth Sandoval and a copy is provided, No citations will be issued during this visit.
SUPERVISORS NAME: Julio Montes
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE: DATE: 03/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/09/2022
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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