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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 410508691
Report Date: 11/06/2020
Date Signed: 11/23/2020 11:36:55 AM

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:OUR LADY OF PEACE RESIDENTIAL CARE HOMEFACILITY NUMBER:
410508691
ADMINISTRATOR:SANCHEZ, LOLITA D. QUEFACILITY TYPE:
740
ADDRESS:1669 WOLFE DRIVETELEPHONE:
(650) 574-0498
CITY:SAN MATEOSTATE: CAZIP CODE:
94402
CAPACITY:6CENSUS: 2DATE:
11/06/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Lolilta Sanchez and Maria HartTIME COMPLETED:
05:00 PM
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On 11/6/2020, Licensing Program Analyst, (LPA) Shabana Buksh conducted a virtual case management inspection regarding Covid -19 concerns/issues that was reported to CCLD. Reporting party also reported concerns regarding the health and safety of the residents at the facility. LPA virtually met Licensee/Administrator, Lolita Sanchez and staff, Maria Hart. There are currently 2 residents residing at the facility. LPA reviewed residents' records with Licensee.

LPA virtually met both the residents. Staff took temperature of both the residents. R1's temperature showed 95.6 F and R2's was 96.8 F. LPA observed signs related to Covid -19 was posted. The testing statement had a log with Covid -19 symptoms for visitors, thermometer to take temperatures and hand sanitizers. LPA delivered PPE LPA provided Covid -19 Technical Assistance and requested staffing plan (LIC 500), and Emergency disaster plan (LIC 610) that includes infectious control and prevention precautions to include a contingency plan for the flu that reflects considerations specific to the facility from Licensee. The due date to submit the documents is 11/20/2020.

At close, LPA also advised Licensee to stay up to date on COVID-19 and PINs/CCL website (provided links via email). Reminded them to report any positive cases of COVID-19 immediately to local Public Health Department, their local Ombudsman, and CCLD.

Report was emailed to Licensee.

SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Shabana BukshTELEPHONE: (650) 266-8810
LICENSING EVALUATOR SIGNATURE:

DATE: 11/06/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2020
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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