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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 410508766
Report Date: 11/29/2021
Date Signed: 11/30/2021 08:38:00 AM

Document Has Been Signed on 11/30/2021 08:38 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME:RICE RESIDENTIAL CARE FACILITYFACILITY NUMBER:
410508766
ADMINISTRATOR:PALATTAO, RUBY M.FACILITY TYPE:
735
ADDRESS:45 RICE STREETTELEPHONE:
(650) 992-8076
CITY:DALY CITYSTATE: CAZIP CODE:
94014
CAPACITY: 5CENSUS: 3DATE:
11/29/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Ruby Palattao - Licensee/AdministratorTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Fernandes-Goes conducted an unannounced Annual Required – 1 yr. Infection Control inspection to this facility and met with Licensee/Administrator Ruby Palattao. Clients were present at the facility during visit. Facility has 3 clients that are not attending day programs at this time due to no ADP being closed. Facility has other activity plans for clients during the day.

LPA arrived at the facility and had temperature checked and logged into visitor’s binder. During facility tour on 11/29/2021 with licensee/administrator facility was found to be at a comfortable temperature with all exits free from obstruction. Client’s bedrooms were not inspected due to clients' request; common areas, kitchen & food storage areas were inspected. Fire Extinguisher was found to be last charged on 10/2020 at the time of the visit - still in the green area of charged. Smoke Detectors & Carbon monoxide detector was found to be operational during the visit. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations on this day at the time of the visit. Toxins are stored in a locked cabinet under the kitchen sink. Dangerous items were stored inaccessible to clients. There was a supply of cleaners, hygiene products and paper products available for clients. Hot water temperature measured 110.6 degrees F within Title 22 acceptable regulations of 105 ro 120 degrees F

Infection Control:
Facility has submitted a mitigation program plan that hasn't been approved. Posters have been placed at facility and entrance has small table with hand sanitizer and other items designated for visitors and staff before coming into work. Facility has PPE supply stored in the kitchen and isolation room. Facility has not hired or admitted anyone new since COVID-19. Clients’ medications are stored and locked in the kitchen area. Facility has a 30-day supply of medication for clients. Clients aren’t wearing masks inside the facility, however; staff stated that they are able to wear masks when going on outings. All staff had masks on during this visit.
Continue LIC 809-C
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Carla Fernandes-Goes
LICENSING EVALUATOR SIGNATURE: DATE: 11/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/29/2021
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
CCLD Regional Office,
, CA
FACILITY NAME: RICE RESIDENTIAL CARE FACILITY
FACILITY NUMBER: 410508766
VISIT DATE: 11/29/2021
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In addition, facility has a designated area for visitors which are being allowed for scheduled visits. Clients have also available virtual and telephone calls when contacting with family members and others. Staff had all PPE training required on file and are working towards obtaining N-95 fit testing.

LPA advised facility to contact Local County Public Health and DSS/CCL Community Care Licensing immediately if symptoms or COVID-19 + in the facility. Disaster Drills have been conducted every six months with the last one being conducted on 10/6/2021.

There were no deficiencies cited at this time.

Department is requesting Licensee to update and submit the following documents to CCLD by 12/06/2021:

LIC 500 Personnel Report
LIC 9120 Clients/Residents Roster
LIC 400 Affidavit Regarding Resident Cash Resources
LIC 402 Surety Bond
LIC 610 Emergency Preparedness
Copy of Administrator Certificate

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Carla Fernandes-Goes
LICENSING EVALUATOR SIGNATURE:

DATE: 11/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2021
LIC809 (FAS) - (06/04)
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