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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415201849
Report Date: 09/16/2021
Date Signed: 09/16/2021 02:39:46 PM

Document Has Been Signed on 09/16/2021 02:39 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:EAST WEST CARE REDWOOD CITY IIFACILITY NUMBER:
415201849
ADMINISTRATOR:CYNTHIA ADVINCULAFACILITY TYPE:
740
ADDRESS:1018 CLINTON STREETTELEPHONE:
(650) 261-3593
CITY:REDWOOD CITYSTATE: CAZIP CODE:
94061
CAPACITY: 8CENSUS: 4DATE:
09/16/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Emma AdvinculaTIME COMPLETED:
03:00 PM
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On 09/16/2021, Licensing Program Analyst (LPA) Jaime Vado toured facility's building and grounds. LPA met with caregiver Emma Advincula and explained purpose of today's inspection. 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. PPE supply is observed as in place. 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. First-aid kit is inspected and complete. A Disaster and Mass Casualty Plan dated 03/23/2020 is observed. There are 4 residents present and 2 staff. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed. LPA is unable to review staff files due to the administrator locking the storage area. LPAs discussed entry question procedures and masking requirements as reminders. Staff were not wearing masks due to cleaning but masks are present for their use. Signs are present regarding masking and distancing but LPAs discussed the need to add more reminder signs for residents regarding cough etiquette, resident masking, and social distancing. LPA Vado will send licensee additional signs to add to facility.

The following updated forms are requested to be submitted to CCLD by 09/24/2021:

• Administrator Certificate
• LIC 308 Designation of Administrative Responsibility
• LIC 309 Administrative Organization
• LIC 500 Personnel Report
• LIC 610E Emergency Disaster Plan
• Updated lease agreement or control of property information

Report reviewed with caregiver Emma.
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Jaime Vado
LICENSING EVALUATOR SIGNATURE: DATE: 09/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/16/2021
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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