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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 410508554
Report Date: 11/15/2022
Date Signed: 11/15/2022 04:44:37 PM

Document Has Been Signed on 11/15/2022 04:44 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:RUSTAN ADULT RESIDENTIAL CARE HOMEFACILITY NUMBER:
410508554
ADMINISTRATOR:RUIZ, NECITAFACILITY TYPE:
735
ADDRESS:147 PLYMOUTH CIRCLETELEPHONE:
(650) 878-8297
CITY:DALY CITYSTATE: CAZIP CODE:
94015
CAPACITY: 6CENSUS: 6DATE:
11/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Caregiver, Rowenda ParadoTIME COMPLETED:
11:10 AM
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On 11/15/2022, Licensing Program Analyst(LPA) Murial Han conducted an unannounced annual inspection. LPA met with caregiver, Rowenda Parado and explained the purpose of the inspection.

LPA toured facility and grounds. No accessible bodies of water or fire safety hazards observed. Infection control practices are reviewed: entry procedures, staff training and policies, resident and staff daily monitoring records, containment strategies. There are 2 residents present during the inspection.

This is a single level facility with 5 bedrooms. The 3 semi-private room with beds observed to be 6" apart or 3 feet apart with head-to-toe orientation. PPE supply and the environmental cleaning supply are adequate, bathrooms are equipped with liquid soap and LPA recommended to replace the cloth towel to paper towel. Hand washing instructions posted by the sink. COVID-19 signs are observed at the facility.

Medications, and toxins stored appropriately and inaccessible to residents. A comfortable temperature is maintained, lighting is sufficient for comfort and safety. First-aid kit is inspected and complete.

During the inspection, the caregiver reported the facility's administrator is Leah Ruiz and LPA requested for documents to update the administrator: . A written letter from the Licensee appointing the current administrator, LIC 500, LIC 501 and LIC 308 to be submitted to CCL by 11/18/2022.

No deficiency cited today.
This report is reviewed and discussed with the caregiver. A copy is provided.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE: DATE: 11/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/15/2022
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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