410508702-11-17-2022-14-AS-KWAS-CL9V9V-20221117151458

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 410508702
Report Date: 11/17/2022
Date Signed: 11/17/2022 03:15:04 PM

Document Has Been Signed on 11/17/2022 03:15 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
Lookup Error,
, CA

FACILITY NAME:	MANALO'S BOARD AND CARE		FACILITY NUMBER:	410508702
ADMINISTRATOR:	MARITA DE ASIS		FACILITY TYPE:	740
ADDRESS:	807 BYRON DRIVE		TELEPHONE:	(650) 755-7883
CITY:	SOUTH SAN FRANCISCO	STATE: CA	ZIP CODE:	94080
CAPACITY:	6	CENSUS: 5	DATE:	11/17/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Lele Manuel		TIME COMPLETED:	03:26 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On November 17, 2022, Licensing Program Analyst (LPA) Walters arrived unannounced to conduct an annual required 1-year inspection. This visit will focus primarily on the infection control practices of this facility. Upon arriving at the facility LPA was greeted by Staff, Lele Manuel who granted LPA entrance into the facility. LPA learned that the facility had a change of Administrator that has not yet been reported to Community Care Licensing. The current Administrator is Josifina Manalo (6026944740 exp. 2024) who was not available for today's visit. LPA is requesting that the Licensee/ Administrator updates the Administrator for this facility with community care licensing. LPA toured the facility with staff and made the following observations: All staff were wearing mask. At the entrance of the facility there is a sign in sheet with hand sanitizer and disposable mask for visitors. LPA observed signage that promoted proper hand washing and droplet precaution. Signs were also posted outside with the facilities visiting policy. The home was a comfortable temperature, clean and was observed to be in good repair. Bathrooms were stocked with hand washing supplies and paper products. There is at least a 30 day supply of cleaning, incontinence products, and personal protective equipment. Cleaning supplies were locked closet in the hallway closer. Knives were locked in a cabinet in the kitchen. All bedrooms were furnished as required per regulation. Fire extinguishers were charged. All exits and walkways were found to be unobstructed and were free of debris. Smoke and carbon monoxide detectors were tested and found to be operational. Staff were able to ensure that all auditory alarms were in working order. Continued on LIC 809 C

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Katrina Walters	TELEPHONE: 707-588-5097
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA

FACILITY NAME: MANALO'S BOARD AND CARE	FACILITY NUMBER: 410508702
	VISIT DATE: 11/17/2022

NARRATIVE

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LPA reviewed 3 staff and 4 resident records. Facility stores resident vaccine cards in their appropriate binder. Staff that were present at the facility showed LPA their vaccine cards. The facility staff records do not include the staff vaccine cards. LPA advised that Administrator obtains copies of all staff vaccine cards in file. LPA learned that resident R1 had a change of condition that resulted in them becoming bedridden. R1's physician report did not indicate the change of condition. LPA is requesting that Licensee/Administrator updates R1's 602. If R1 is considered bedridden by their physician the Licensee/Administrator will need to request a bedridden exception.

LPA and staff observed that the community care licensing poster was not posted.

LPA is requesting that the following items by 11/30/22:

Change of Administrator forms: (Copy of updated Administrator Certificate, LIC215, LIC500, LIC308, LIC501, detailed employment/education history.
Resident Roster
infection control training
Updated 602 for R1
picture as proof that the facility has posted the community care licensing complaint poster

LPA issued 2 technical violations during this visit. No deficiencies cited during visit.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Katrina Walters	TELEPHONE: 707-588-5097
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

LIC809 (FAS) - (06/04)

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