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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 410508766
Report Date: 10/04/2024
Date Signed: 10/04/2024 11:40:35 AM

Document Has Been Signed on 10/04/2024 11:40 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:RICE RESIDENTIAL CARE FACILITYFACILITY NUMBER:
410508766
ADMINISTRATOR/
DIRECTOR:
PALATTAO, RUBY M.FACILITY TYPE:
735
ADDRESS:45 RICE STREETTELEPHONE:
(650) 992-8076
CITY:DALY CITYSTATE: CAZIP CODE:
94014
CAPACITY: 5CENSUS: 5DATE:
10/04/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Administrator, Ruby PalattaoTIME VISIT/
INSPECTION COMPLETED:
11:50 AM
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On October 4, 2024, Licensing Program Analysts (LPAs) Komal Charitra and Yi Sam Jian conducted an unannounced annual inspection. LPAs met with Administrator, Ruby Palattao and explained the purpose of the visit.

LPAs toured the facility inside and outside including all of client rooms, common areas & kitchen. The indoor and outdoor passageways were free of obstruction. No accessible bodies of water of fire safety hazards observed. This is a two story facility; client bedrooms, kitchen, common area, bathroom, etc. on the second floor, and staff bedroom, garage, family room on the first floor.

Second floor living room and dining room was observed to be clean, free from tripping hazards and odor-free. A comfortable temperature of 70 degrees F is maintained and lighting is sufficient for comfort. LPA toured kitchen and observed two day perishable and seven day non-perishables. Sharps, chemicals and medications were observed to be locked an inaccessible to clients. LPAs observed three client bedrooms; two shared rooms and one single-private room. All rooms were observed to be in good repair with required furniture. One full bathroom was observed on the second floor; equipped with liquid soap, non-skid mats, and a hand dryer. LPA advised administrator to only use liquid soap instead of bar soaps. Water temperature throughout the facility measured at 113 degrees F.

LPAs toured the first floor; staff family room, bedroom and full bathroom was observed. Garage on the first floor was toured, washer and dryer were in good repair. Backyard was observed to have a shed with extra clothes. Extra linen was observed present and first aid kit was observed to be completed. Carbon monoxide monitor is working properly. All fire extinguishers have been checked and current as of January 2024. Emergency drills are logged and done quarterly.

LPAs reviewed 5 client records and 4 staff records. Resident records are updated, complete and signed. Staff records are complete, with training logs that have met the basic requirement. Medication review was done, and all medications are accounted for, and centrally stored medication records are updated. No citations are issued during the visit. LPAs reviewed report with administrator and a copy is provided.

Administrator to submit the following updated documents to CCL by 10/11/2024:
-LIC500 Personnel Report, LIC308 Designation of Administrative Responsibility, LIC610D Emergency Disaster Plan
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE: DATE: 10/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/04/2024
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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