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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 410508402
Report Date: 08/04/2022
Date Signed: 08/04/2022 04:32:01 PM


Document Has Been Signed on 08/04/2022 04:32 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:B & B RESIDENTIAL FACILITIESFACILITY NUMBER:
410508402
ADMINISTRATOR:BULJAN, ANTE & SLAVAFACILITY TYPE:
740
ADDRESS:13 W. 38TH AVENUETELEPHONE:
(650) 570-5124
CITY:SAN MATEOSTATE: CAZIP CODE:
94403
CAPACITY:6CENSUS: 6DATE:
08/04/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Florencia Cueva and Gigi ReyesTIME COMPLETED:
04:30 PM
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LPA Audrey Jeung toured facility and grounds, consisting of 6 private client bedrooms, each with a full bathroom, and a staff bedroom, plus 1 common full bathroom, kitchen, dining/living room.
The upper level has a separate entrance and is not used as part of the RCFE. It is a rental unit. There is a laundry room on the ground level, which is also where there are staff accommodations. No accessible bodies of water are present. Toilet and bathing facilities are equipped with grab bars and nonskid flooring material. First-aid kit is inspected and complete. Medications, toxins and sharps are stored appropriately and inaccessible to clients, a comfortable temperature is maintained, and lighting is sufficient for comfort and safety.
Infection control practices are reviewed: entry procedures, staff training and policies, resident monitoring, containment strategies, environmental preparation and cleaning. PPE supply is adequate. A Disaster and Mass Casualty Plan is posted. There are 6 residents present, and 2 staff. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed, in addition to health screenings, TB test results, and valid first-aid training. Ante Buljan and Noralee Reyes are certified RCFE administrators (x 1/23 and 9/23) that oversee facility operations.

The following updated forms/information are requested to be submitted to CCLD BY 8/18/22:

• LIC 309 Administrative Organization
• LIC 308 Designation of Administrative Responsiblilty
• LIC 500 Personnel REport
• LIC 610E Emergency Disaster Plan
• LIC 9282 Infection Control Plan

Proof of current liability insurance is given to LPA today.
No deficiencies of the RCFE California Code of Regulations, Title 22, Division 6, Chapter 8 are observed.
See 1 Advisory Note given to Ms. Reyes for additional information.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:
DATE: 08/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/04/2022
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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