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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600021
Report Date: 11/10/2022
Date Signed: 11/10/2022 11:41:30 AM

Document Has Been Signed on 11/10/2022 11:41 AM - 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:FAMILY HOUSING AND ADULT RESOURCES, INC. ADULT DAYFACILITY NUMBER:
415600021
ADMINISTRATOR:CONSTANCE LYNN FORTINOFACILITY TYPE:
775
ADDRESS:205 WEST 20TH AVENUETELEPHONE:
(650) 573-3341
CITY:SAN MATEOSTATE: CAZIP CODE:
94403
CAPACITY: 42CENSUS: 6DATE:
11/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:Program Director, Connie FortinoTIME COMPLETED:
11:50 AM
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On November 10, 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 Program Manager, Colin Behr and Program Director, Connie Fortino joined shortly thereafter. LPA explained the purpose of the visit. LPA observed the COVID-19 screening log for staff, clients, and visitors.

LPA toured the facility and grounds. No accessible bodies of water or fire safety hazards observed. This is a single story day program with 9 classrooms, 4 bathrooms, a kitchen, a conference room and an office room. During the visit, LPA observed staff and clients having lunch together. Tables and chairs in the classrooms were observed to be 6ft apart. Staff were observed to be wearing a face coverings. LPA toured the kitchen and observed toxins, chemicals, and sharps locked and stored appropriately and inaccessible to clients. Kitchen was equipped with liquid soap, paper towels, and a trash can with a fitted lid. According to the Program Director, the day program does assist clients with administration of medications, however the clients at the program currently are not taking any medications. LPA observed all 4 bathrooms to be equipped with liquid soap, paper-towels, hand-washing signs, a trash can with a fitted lid, and grab bars. All bathrooms were clean and odor free.

All 9 classrooms were observed to be clean and free from tripping hazards. A comfortable temperature of 70 degrees F is maintained and lighting is sufficient for comfort. LPA observed PPE supply and a storage room present. COVID-19 signage was observed to be posted throughout the facility. According to the Program Manager, the facility is sanitized thoroughly 3x a day.

LPA requests the following forms to be submitted to CCLD by 11/17/22:
-LIC308 Designation of Administrative Responsibility
-LIC500 Personnel Report
-LIC610D Emergency Disaster Plan

No citations issued during the visit. Report is reviewed with Program Manager and a copy is provided.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE: DATE: 11/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/10/2022
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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