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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415201202
Report Date: 03/10/2022
Date Signed: 03/10/2022 01:55:59 PM


Document Has Been Signed on 03/10/2022 01:55 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
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066



FACILITY NAME:BRITANNIA PLACEFACILITY NUMBER:
415201202
ADMINISTRATOR:DELPHINE WILLIAMSFACILITY TYPE:
740
ADDRESS:1515 MADDUX DRIVETELEPHONE:
(650) 369-8383
CITY:REDWOOD CITYSTATE: CAZIP CODE:
94061
CAPACITY:6CENSUS: 5DATE:
03/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Mark WilliamsTIME COMPLETED:
11:30 AM
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On this day at 1000 hours, Licensing Program Analysts (LPA) Jaime Vado conducted an unannounced infection control annual required inspection. LPA met with administrator Mark Williams and explained purpose of today's inspection.

LPA toured facility's building and grounds. Upon entry LPA was screened for COVID with temperature taken and COVID related questions asked. LPAs toured facility with Mark. It is suggested that more COVID signs be present within facility. Additional social distancing signs, cough etiquette signs, face covering, and COVID symptoms signs to be posted in main hallway. 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 and staff monitoring, containment strategies, environmental preparation and cleaning are in place. PPE supply is observed as in place. LPA informed Mark that additional PPE is available from the regional office upon request. Medications, toxins and sharps are stored appropriately and inaccessible to clients. Facility ambient temperature is comfortable and lighting is sufficient for residents and staff safety. Toilet and bathing facilities are equipped with grab bars and non-skid flooring material. Liquid soap is available in resident bathrooms and paper towels for resident use. Hand washing signs are present. First-aid kit is inspected as complete. A Disaster and Mass Casualty Plan observed. There are 5 residents and 2 staff present additionally the administrator is present. All staff wearing masks. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed as current. Administrator certificate expires 5/19/2022. All residents and staff are fully vaccinated and with booster as of 10/2022. Mitigation plan is present and current.

The following updated forms are requested to be submitted to CCLD by 03/17/2022:

• LIC 308 Designation of Administrative Responsibility
• LIC 500 Personnel Report
• LIC 610E Emergency Disaster Plan
• Updated copy of administrator certificate

No deficiencies cited. Report is reviewed with Mark.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:
DATE: 03/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/10/2022
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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