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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415201849
Report Date: 08/08/2022
Date Signed: 08/08/2022 02:44:38 PM

Document Has Been Signed on 08/08/2022 02:44 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: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: 7DATE:
08/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Emma AdvinculaTIME COMPLETED:
12:15 PM
NARRATIVE
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On this day Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced infection control annual inspection visit. LPA met with facility caregiver Emma Advincula and let her know the purpose of today's visit. Upon entry LPA had temperature taken but not asked COVID symptoms questions. LPA did observe no staff wearing masks upon entry. Masks were later worn by staff during the inspection. LPA later met with the licensee Cynthia Advincula who arrived during the inspection.

LPA toured the physical plant inside and out. There are no accessible bodies of water or fire safety hazards observed. COVID postings are not present on the front door or inside the facility. Hand washing signs are observed in resident bathrooms. Hand sanitizer is observed as available near the front door of the facility. Facility ambient temperature is warm and comfortable, and lighting is sufficient for residents and staff safety. Medications and knives are observed as locked and not accessible to residents. First aid kit is observed as complete. Toilet and bathing facilities are equipped with grab bars and non-slip mats. Liquid soap is available. Paper towels are present for resident use. Water temperature is taken in a common resident bathroom at 120F. Laundry machines and dryers are functioning. Emergency food supply, dry goods, and perishables are observed as in place. Fire extinguisher located in dining room/kitchen are is observed as inspected on 2/15/2022. Appears to be charged and ready for use.

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 are stored appropriately and inaccessible to clients. LPA reviewed training record. Resident temperature logs and staff logs are current. All staff are vaccinated and boosted. Residents are vaccinated and boosted. Facility PPE supplies are observed as in place.

A disaster and mass casualty plan is present and current. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed. LPA identified two staff, S1 and S2, that are not associated. Administrator certificate is viewed as current expiring 10/05/2023. LIC808 is discussed and is not current LPA is requesting updated LIC808 to be sent to licensing by 08/12/2022

LPA is requesting the following updated forms to be received by 08/12/2022:

• Copy of administrator Certificate
• LIC 308 Designation of Administrative Responsibility
• LIC 500 Personnel Report
• LIC 610E

Civil penalty is being assessed today at $100 x 2 (two staff not associated) = $200

Report is reviewed with administrator. Deficiencies cited on the following 809D.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Jaime Vado
LICENSING EVALUATOR SIGNATURE: DATE: 08/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/08/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 08/08/2022 02:44 PM - It Cannot Be Edited


Created By: Jaime Vado On 08/08/2022 at 10:58 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: EAST WEST CARE REDWOOD CITY II
FACILITY NUMBER: 415201849

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/08/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/09/2022
Section Cited
CCR
87355(e)(2)

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Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c)
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Administrator shall ensure to submit a criminal record clearance transfer request to the licensing office for S1 by the POC due date. Also submit proof of correction and a written plan outlining how this violation will be avoided in the future to licensing office by due date. Failure to correct this deficiency by due date may result in a civil penalty of $100 per day.
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This requirement was not met as evidenced by: Based on records review, licensee failed to request a transfer of criminal record clearance for S1 and S2 which poses an immediate health and safety risk to clients in care. It is confirmed that S1 and S2 are not associated to the facility on this day 8/8/2022.
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Immediate civil penalty of $100 is being assessed on this day for S1 and S2 totalling $200.
Type B
08/12/2022
Section Cited
CCR87307(a)

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Personal Accommodations and Services - (a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility.
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Administrator shall ensure a designated staff room is available for all staff for comfort and privacy if sleeping overnight. Administrator shall submit a plan of action in writing to correct the deficiency and shall address the designated bedrooms for staff.
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This requirement was not met as evidenced by: LPA observed two staff sleeping on living room couches before entering facility. During the inspection LPA observed the staff removing their beddings from two living room couches.
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Plan of action in writing and facility sketch LIC999 with labels to show the designated rooms for staff to sleep in over night. This shall be received in licensing no later than 8/12/2022.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Jackie Jin
LICENSING EVALUATOR NAME:Jaime Vado
LICENSING EVALUATOR SIGNATURE:
DATE: 08/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/08/2022


LIC809 (FAS) - (06/04)
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