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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 410508446
Report Date: 09/15/2022
Date Signed: 09/15/2022 12:05:16 PM


Document Has Been Signed on 09/15/2022 12:05 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:VANESSA CARE HOME IIFACILITY NUMBER:
410508446
ADMINISTRATOR:GALATI, IDAFACILITY TYPE:
740
ADDRESS:1640 ELEANOR DRIVETELEPHONE:
(650) 863-4262
CITY:SAN MATEOSTATE: CAZIP CODE:
94402
CAPACITY:6CENSUS: 6DATE:
09/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Administrator/Licensee, Ida GalatiTIME COMPLETED:
12:07 PM
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On September 15, 2022, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced annual infection control inspection. LPA met with Administrator, Ida Galati and explained the purpose of the visit. Upon arrival, LPA observed the COVID signage posted on the front door. LPA was screened at entry point and Administrator was able to provide screening log documentation for visitors, however Administrator was not able to provide screening log documentation for residents and staff.

LPA toured facility and grounds. No accessible bodies of water or fire safety hazards observed. This is a single story facility with 8 bedrooms and 8 full bathrooms. LPA toured the facility with the Administrator and observed 6 resident rooms; all of which are private rooms with full baths. In addition, LPA observed room #6; with a full bath and room #7 (indicated on floor plan) being utilized as a staff room at this time. There is a shared staff bathroom in the facility observed outside of room #8. All bathrooms are equipped with liquid soap, paper-towels, hand-washing signs, and a trash can with a fitted lid.

Infection control practices are reviewed: COVID signage throughout the facility, face coverings, 30-day PPE supply, and entry procedures. LPA toured the living room and dining room and it was clear and odor-free. In addition, the living room and dining room was spacious for residents and was observed to be clear from any tripping hazards. A comfortable temperate of 73 degrees F is maintained and lighting is sufficient for comfort.

LPA toured the kitchen and the medications and sharps were stored appropriately and inaccessible to residents. Kitchen sink was equipped with liquid soap, paper towels, and hand washing signs. LPA observed 2 day perishable and 7 day non-perishable present. LPA Charitra toured the garage and observed washer and dryer to be in good repair and toxins to be locked in a cabinet. LPA also observed extra food supply present. Extra linen was observed to be present and first aid kit was observed to be completed.

LPA requests the following forms to be submitted to CCLD by 9/22/22:
-LIC308 Designation of Administrative Responsibility
-LIC500 Personnel Report
-LIC610E Emergency Disaster Plan
-LIC400 Resident Cash Resources
-Administrator Certificate

No citations are issued during the visit. LPA reviewed report with Ida Galati and a copy is provided.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 09/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/15/2022
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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