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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 410508557
Report Date: 11/17/2022
Date Signed: 11/17/2022 01:30:12 PM


Document Has Been Signed on 11/17/2022 01:30 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: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: 3DATE:
11/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Corazon MedinaTIME COMPLETED:
01:30 PM
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On this day Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced annual inspection visit focused on COVID infection control. LPA met with caregiver Amara Balatbat and explained purpose of today's visit. Later during visit LPA met with back up administrator Corazon Medina sister of the licensee.

Upon entry LPA was not initially screened with COVID screening questions or having temperature taken but LPA advised on doing so for all visitors and staff entering the facility. Even if it is licensing or ombudsman. LPA was properly screened after this prompting. Prior to entry, LPA did not see any COVID postings on the front door entering the facility. LPA toured facility's building and grounds. LPA did not observe COVID postings through out the facility. No accessible bodies of water or fire safety hazards observed. Infection control practices are reviewed: entry procedures, staff training and policies, resident monitoring, containment strategies, environmental preparation and cleaning. Resident and staff daily temperature log is observed as up to date. PPE supply is observed as in place. Medications, toxins and sharps are stored appropriately and inaccessible to clients. Fire extinguishers are observed as being inspected on 07/06/2022. Of the extinguishers observed all are charged and ready for use. Facility ambient temperature is comfortable. Facility lighting is sufficient for residents and staff safety. Toilet and bathing facilities are equipped properly. Water temperature is tested at 116F in a common bathroom on ground floor. Resident bathrooms did have hand washing signs present. All resident rooms are equipped with required furniture and light fixtures. Non-slip mats and grab bars are present. Liquid soap is available and paper towels. First-aid kit is inspected and complete. A Disaster and Mass Casualty Plan is posted. There is 1 resident and 2 staff on site today. The other 2 residents are attending their day programs. Staff is observed not wearing a mask. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed as current. Administrator certificate is observed expired on 11/01/2022. According to the administrator, she does have a current certificate and will send to the Department.

The following updated forms are requested to be submitted to CCLD by 11/24/2022:

• LIC 308 Designation of Administrative Responsibility
• LIC 500 Personnel Report
• LIC 610E Emergency Disaster Plan
• Copy of administrator certificate and requested documents to have the name changed

Technical violations did occur today and are attached on the following LIC9102TV.

Report is reviewed with Corazon Medina.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:
DATE: 11/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/17/2022
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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