<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600011
Report Date: 12/06/2022
Date Signed: 12/06/2022 01:30:05 PM


Document Has Been Signed on 12/06/2022 01:30 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:COMFORT HOME IIFACILITY NUMBER:
415600011
ADMINISTRATOR:CAINGCOY, RUFINAFACILITY TYPE:
740
ADDRESS:652 VANESSA DRIVETELEPHONE:
(650) 349-0843
CITY:SAN MATEOSTATE: CAZIP CODE:
94402
CAPACITY:6CENSUS: 5DATE:
12/06/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:38 PM
MET WITH:Administrator, Jenilee PatalotTIME COMPLETED:
01:40 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On December 6, 2022, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced annual infection control inspection. Upon arrival, LPA observed the COVID-19 signage posted at the front entrance. LPA met with Administrator Jenilee Patalot and Licensee, Rufina Caingcoy and explained the purpose of the visit. LPA observed a copy of residents, visitors, and staff screening log documentation.

LPA toured the facility and grounds. No accessible bodies of water or fire safety hazards observed. This is a single story home with 5 resident rooms, 1 staff room, 2 full bathrooms and an office/storage room. LPA toured the facility with the administrator and observed living room and dining room to be clean and free from any tripping hazards. A comfortable temperature of 78 degrees F is maintained and lighting is sufficient for comfort. During the visit, LPA observed two residents having lunch together and maintaining social distancing.

LPA toured the resident rooms and observed all 5 resident rooms to be private rooms. LPA observed 2 full bathrooms to be equipped with liquid soap, paper towels, and non-skid mats. LPA advised administrator to ensure that trash cans have a fitted lid and to put up hand-washing signs. Bathrooms were odor-free and in good repair. LPA observed extra linen present. First aid kit was observed to be completed. LPA observed Room 3 (as indicated on the facility floor plan) to have a working door alarm. LPA toured the kitchen and observed 2 day perishable and 7 day non-perishable. Sharps, chemicals, and medications were observed to be locked and inaccessible to residents.

LPA toured the garage and observed the extra food supply and supplies closet. In addition, LPA observed a washer and dryer outside to be in good working condition. 30-day PPE supply was present. LPA observed the office/storage room located right next to the garage to have personal belongings.

Infection control practices are observed: entry procedures, daily monitoring log for staff, residents and visitors, 30-day PPE supply, face coverings for staff, containment strategies, staff training and policies, COVID-19 signage posted throughout the facility.

CONT. to 809C
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 12/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/06/2022
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


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: COMFORT HOME II
FACILITY NUMBER: 415600011
VISIT DATE: 12/06/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
LPA requests the following forms to be submitted to CCL by 12/13/22:
-LIC308 Designation of Administrator Responsibility
-LIC500 Personnel Report
-LIC610E Emergency Disaster Plan
-Administrator Certificate

No citations will be issued during this visit. Report is reviewed with Administrator and a copy is provided.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2