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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 410508853
Report Date: 10/15/2021
Date Signed: 10/15/2021 12:08:04 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:CLM CARE HOMEFACILITY NUMBER:
410508853
ADMINISTRATOR:MARINELA M. LIMFACILITY TYPE:
740
ADDRESS:1320 VALOTA ROADTELEPHONE:
(650) 298-9835
CITY:REDWOOD CITYSTATE: CAZIP CODE:
94061
CAPACITY:6CENSUS: 5DATE:
10/15/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Bethany Dinh and Quan TranTIME COMPLETED:
12:00 PM
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On 10/15/2021 at 0930hrs Licensing Program Analyst (LPA) Jaime Vado and Komal Charitra conducted an unannounced prelicensing inspection visit. LPA met with licensee/administrator Bethany Dinh and Quan Tran.

Upon arrival new administrator pre screened LPAs and took temperatures in accordance with COVID19 visitation procedures. This is a single floor facility. LPAs made observations through out the facility. All staff are observed wearing masks. Residents are present on this day. There are two staff on duty in addition to new administrator/licensees. LPAs inspected all facility bathrooms and all are in good condition. Faucets operate appropriately. Non-skid mats and grab bars are in place in all showers. Water temperatures are taken in bathroom faucets ranging from 107F to 110F. One resident room has a private bathroom located at the far end of the facility. Water temp measured at 109F. This room is also designated as a COVID19 isolation room. All bathrooms have liquid soap available. Hand sanitizers are also observed as available to residents. COVID19 related signs are present through out facility. Bedding in room six was inspected and is in good condition. Spare linens are observed as in place. All bedrooms contained the required furniture and lighting requirements per CCLD regulations. Smoke detectors are hard wired through out facility. Carbon monoxide detector is in place. Fire extinguisher is within normal operating range and last inspected in July 2021. Cleaning solutions are observed in locked bathroom closet at the front of the facility. Medications are observed as current and locked in cabinets in the office area. Facility PPE is present. Facility food supplies are in place. Emergency egress areas are clear of obstructions. Backyard contains a storage shed which holds extra resident incontinence products and other items in storage. No firearms on the premises. Resident and staff files are reviewed as current. All residents and staff are vaccinated.

As a result of inspection today, the physical plan of this home is in substantial compliance within the regulation requirements for a Residential Care Home for the Elderly today, and is pending the completion of all documentation and the final approval of the Centralized Application Unit (CAU).

Component III is conducted today with new licensees.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2021
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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