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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 410508766
Report Date: 12/21/2022
Date Signed: 12/21/2022 04:23:49 PM

Document Has Been Signed on 12/21/2022 04:23 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: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: 0DATE:
12/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Ruby PalattaoTIME COMPLETED:
04:30 PM
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On this day Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced annual required 1 year inspection focused on COVID infection control. LPA met with licensee Ruby Palattao and explained the purpose of today's inspection.

Due to renovations being done at the facility there are no residents present. LPA initially was not COVID screened with temperature or symptoms questions. Currently there are no COVID postings in place besides hand washing sign in common resident bathroom in the main hallway where resident rooms are located. LPA advised that the COVID signs need to be put back up in common areas and on front door of facility before residents move back in. There are no accessible bodies of water or fire safety hazards observed. Infection control practices are reviewed: entry procedures, staff training and policies, resident monitoring, containment strategies, environmental preparation and cleaning. Resident and staff daily temperature log is not present due to the residents not present in the facility at this time. LPA advised that these records are to be maintained and continued once residents move back into the facility. The licensee did confirm that they are still taking these temperatures and she explained her procedure. PPE supply is observed as in place. Medications, toxins and sharps are stored appropriately and inaccessible to clients. Fire extinguisher is observed adjacent to the kitchen as tagged and being inspected on 11/03/22. Facility lighting is sufficient for residents and staff safety. Water temperature is tested at 108F in the common bathroom in the hallway of the upper floor. Liquid soap is available, paper towels, and a hand dryer is available in the common bathroom. First-aid kits are inspected as complete. A Disaster and Mass Casualty Plan will be posted. Criminal record clearances or exemptions for facility staff or other individuals who have client contact is reviewed. All staff and residents have been vaccinated.

The following updated forms are requested to be submitted to CCLD by 12/28/2022:

• LIC 500 Personnel Report
• LIC 308 Designated of Facility Responsibility
• LIC 610D Emergency Disaster Plan
• LIC 402 Surety Bond
• Copy of administrator certificate

Report is reviewed with licensee Ruby Palattao.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Jaime Vado
LICENSING EVALUATOR SIGNATURE: DATE: 12/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/21/2022
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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