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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 410508681
Report Date: 03/20/2024
Date Signed: 03/20/2024 12:40:29 PM


Document Has Been Signed on 03/20/2024 12:40 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066



FACILITY NAME:DIAZ RESIDENTIAL CARE HOMEFACILITY NUMBER:
410508681
ADMINISTRATOR:DIAZ, MARIA AND ESTELAFACILITY TYPE:
740
ADDRESS:438 CEDAR STREETTELEPHONE:
(650) 366-1154
CITY:REDWOOD CITYSTATE: CAZIP CODE:
94063
CAPACITY:6CENSUS: 4DATE:
03/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Administrator - Maria DiazTIME COMPLETED:
12:45 PM
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On 03/20/2024 Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced 1 year annual inspection visit. LPA met with administrator Maria Diaz and explained the purpose of today's visit.

LPA toured the facility inside and outside. Emergency exit routes are free and clear of obstructions. The facility's ambient temperature is comfortable and warm. Water is tested in laundry room as being 108F. Residents have an adequate amount of linens and incontinence supplies, incidental supplies, as well as PPE as needed. Multiple fire extinguishers are observed. Last inspected on 06/22/2023. Upon observation of the charge on the dial display it is within the green zone indicating it is charged and ready for use. Carbon monoxide detectors and smoke detectors are present through out the facility. Fire alarm pull box is located next to the front door and one also near the back near the exit that goes to the backyard. Four client bathrooms were observed to be in good repair. Client bathrooms are observed to be in working order with clean shower curtains and non-skid flooring is in place in client bathroom. Facility provides toiletries for client use. 7 day non-perishable food supply and 2 day fresh food supply is observed as in place. Kitchen is observed as operable and clean. Appliances are in good working order. Knives are stored and locked in kitchen cabinet. Insulin for client use is locked and stored in the main kitchen. There are no residents with dementia in the facility at this time.

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SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8865
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:
DATE: 03/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/20/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: DIAZ RESIDENTIAL CARE HOME
FACILITY NUMBER: 410508681
VISIT DATE: 03/20/2024
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Page 2 - LIC809C

Medications are stored and inaccessible in a locked medication. Medications are stored and labeled in containers. Medications are reviewed to be in place. Medication administration record is observed as current for clients reviewed including centrally stored medication log. First aid kit is complete and stored in living room area. On site laundry is available and functioning per observations made. Cleaning supplies are observed as locked.

3 staff records are reviewed. All staff has criminal record clearance and are associated with the facility. Based on record reviews, TB tests, training, CPR/First Aid cards, and personnel files are current. 1 client record is checked and is complete and updated. Disaster drills are conducted monthly per records reviewed. According to administrator each drill is different and varies for each drill conducted. Administrator certificate is observed as expired as of 11/12/2022. Per Maria she has submitted items for renewal and is awaiting certificate. LPA reviewed current training hours for administrator certificate. LPA advised Maria to follow up with administrator certification. Per review with administrator client money is in place and accurate.

The following updated items are requested to be sent to the Department by 03/27/2024:

• LIC610E Emergency Disaster Plan
• LIC 308 Designation of Administrative Responsibility
• LIC 500 Personnel Report
• Updated administrator certificate
• LIC9020 Client Roster
• Certificate of Liability Insurance
• Proof of control of property
• Surety bond with expiration date

Report is reviewed with administrator.
SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8865
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:

DATE: 03/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 03/20/2024 12:40 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066


FACILITY NAME: DIAZ RESIDENTIAL CARE HOME
FACILITY NUMBER: 410508681

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/20/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/27/2024
Section Cited
CCR
87303(a)

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87303(a) Maintenance and Operation: The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents,employees and visitors. This regulation has not been met as evidenced by:
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Facility shall develop a plan to ensure the cleaning and removing of the items from the large table in the front of the facility as it may pose a safety risk for residents and staff. Photo eveidence to be received.
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Per observations made LPA observed a disheveled desk in the living room with papers, tools, tissue boxes, and other items. The items can be knocked over and can pose a safety issue for staff and residents.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8865
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:
DATE: 03/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/20/2024
LIC809 (FAS) - (06/04)
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