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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 410508557
Report Date: 11/05/2021
Date Signed: 11/05/2021 11:30:31 AM

Document Has Been Signed on 11/05/2021 11:30 AM - 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:FARM HILL REST HOMEFACILITY NUMBER:
410508557
ADMINISTRATOR:RYAN, EVELYN B.FACILITY TYPE:
740
ADDRESS:3646 FARM HILL BLVD.TELEPHONE:
(650) 366-6535
CITY:REDWOOD CITYSTATE: CAZIP CODE:
94061
CAPACITY: 6CENSUS: 5DATE:
11/05/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Rolando CapaceteTIME COMPLETED:
11:35 AM
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On 11/5/2021, Licensing Program Analysts (LPA) Jaime Vado and Komal Charitra conducted an unannounced infection control required 1 year inspection. LPA met with caregiver Rolando Capacete and explained purpose of today's inspection.

LPAs toured facility's building and grounds. Upon entry LPAs were screened for COVID with temperatures taken and COVID related questions asked. LPAs toured facility with Rolando. It is suggested that more COVID signs be present within facility. Additional social distancing signs, cough etiquette signs, face covering, and COVID symptoms signs be posted. There are no accessible bodies of water or fire safety hazards observed. Infection control practices are reviewed: entry procedures, staff training and policies, resident monitoring and staff monitoring, containment strategies, environmental preparation and cleaning are in place. PPE supply is observed but have less than 30 day supply of N95 masks, gowns, surgical masks, and gloves. Medications, toxins and sharps are stored appropriately and inaccessible to clients. Facility ambient temperature is comfortable and lighting is sufficient for residents and staff safety. Toilet and bathing facilities are equipped with grab bars and non-skid flooring material. Liquid soap is available in resident bathrooms and paper towels for resident use. Hand washing signs are present. Suggested trash cans and bar soap be removed from female resident private bathroom. First-aid kit is inspected. Two first kits were inspected but require additional band-aids for resident use. A Disaster and Mass Casualty Plan observed. There are 5 residents present and 2 staff present. All staff wearing masks. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed as current. Administrator certificate expires 11/01/2022. All residents and staff are vaccinated with booster as of 09/30/2021. Mitigation plan is present and current.

The following updated forms are requested to be submitted to CCLD by 11/12/2021:

• LIC 308 Designation of Administrative Responsibility
• LIC 500 Personnel Report
• LIC 610E Emergency Disaster Plan
• LIC400 and LIC402 with copy of current surety bond
• Updated copy of administrator certificate

No deficiencies cited. Report is reviewed with Rolando.
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Jaime Vado
LICENSING EVALUATOR SIGNATURE: DATE: 11/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/05/2021
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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