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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 410508725
Report Date: 11/15/2022
Date Signed: 11/15/2022 04:45:25 PM

Document Has Been Signed on 11/15/2022 04:45 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:C AND Z RESIDENTIAL CAREFACILITY NUMBER:
410508725
ADMINISTRATOR:HERRERA, CESAR DE JESUSFACILITY TYPE:
735
ADDRESS:636 SOUTHMOOR DRIVETELEPHONE:
(650) 355-3317
CITY:PACIFICASTATE: CAZIP CODE:
94044
CAPACITY: 10CENSUS: 9DATE:
11/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Administrator, Cesar HerreraTIME COMPLETED:
09:50 AM
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On 11/15/2022, Licensing Program Analyst(LPA) Murial Han conducted an unannounced annual inspection. LPA was greeted by administrator, Cesar Herrera. LPA explained the purpose of the visit.

LPA toured facility and grounds. No accessible bodies of water or fire safety hazards observed. Infection control practices are reviewed: entry procedures, staff training and policies, resident and staff daily monitoring records, containment strategies.

During the inspection, there were 9 residents (5 female and 4 male). There are 3 rooms on 1st floor and 4 rooms on the 2nd floor. The shared room beds observed to be 6" apart or 3 feet apart with head-to-toe orientation. PPE supply and the environmental cleaning supply are adequate, bathrooms are equipped with liquid soap and paper towels, hand washing instruction is posted by the hand washing stations. Trash cans are observed with closed lid. COVID-19 signs are posted in the facility.

Medications, toxins and sharps are stored appropriately and inaccessible to resident, a comfortable temperature is maintained, lighting is sufficient for comfort and safety and food supply was checked and observed to be sufficient. First-aid kit is inspected and complete.

No deficiency cited today. This report is discussed with the administrator. A copy is provided.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE: DATE: 11/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/15/2022
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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