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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 410508376
Report Date: 03/17/2022
Date Signed: 03/17/2022 07:19:16 PM


Document Has Been Signed on 03/17/2022 07:19 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:DOLPHIN PARK REST HOME #3FACILITY NUMBER:
410508376
ADMINISTRATOR:CONANAN, EVELYNFACILITY TYPE:
740
ADDRESS:380 GUNTER LANETELEPHONE:
(650) 593-4965
CITY:REDWOOD CITYSTATE: CAZIP CODE:
94065
CAPACITY:6CENSUS: DATE:
03/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Caregiver, Marites HernandezTIME COMPLETED:
02:45 PM
NARRATIVE
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On March 17, 2022, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced annual infection control inspection. LPA was greeted by the Caregiver, Marites Hernandez and explained the purpose of the visit. LPA was screened at entry point and the Caregiver was able to provide screening log documentation for residents, however, the caregiver was unable to provide LPA with screening log documentation for staff and residents. Upon arrival, LPA observed COVID signage on the front door but LPA discussed the need to add more reminder signage (masking, COVID symptoms, social distancing, cough etiquette) on the front door and throughout the facility.

LPA toured facility and grounds. No accessible bodies of water or fire safety hazards observed. This is a single story with 7 bedrooms (6 private rooms for residents and 1 staff room), 2 full and 4 half bathroom. LPA observed the bathrooms to be equipped with liquid hand soap and hand washing signs. LPA advised caregiver to ensure all bathrooms have the following; paper-towels and a covered trash bin. LPA Charitra indicated that hand-towels and bath-towels should not be present in the bathrooms. LPA toured the kitchen and advised caregiver to switch out hand-towels for paper-towels and disinfectant wipes.

LPA observed 2 day perishable and 7 day non-perishable. LPA observed the 30-day PPE supply. 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. Extra linen was observed to be present.

LPA requests for the following to be sent to CCLD by 3/24/22:
  • LIC308 Designation of Administrative Organization
  • LIC500 Personnel Report
  • Administrator Certificate
  • LIC610D Emergency Disaster Plan

Deficiency of the Residential Care Elderly California Code of Regulations, Title 22, Division 6 is observed and cited on a LIC 809D. Failure to correct the deficiencies may result in civil penalties.

This report is reviewed and discussed with the caregiver; a copy is provided.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 03/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/17/2022
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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Document Has Been Signed on 03/17/2022 07:19 PM - It Cannot Be Edited

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: DOLPHIN PARK REST HOME #3
FACILITY NUMBER: 410508376

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/17/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/24/2022
Section Cited

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Personal Rights: Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
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Violation of this regulation is evidence by: the facility failed to provide documentation for the daily residents and staff members screening log.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 03/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/17/2022
LIC809 (FAS) - (06/04)
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