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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600182
Report Date: 12/28/2021
Date Signed: 12/28/2021 05:12:11 PM

Document Has Been Signed on 12/28/2021 05:12 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:HAWTHORNE HOUSEFACILITY NUMBER:
415600182
ADMINISTRATOR:CARRIE RAMLOW, MSW, PDFACILITY TYPE:
772
ADDRESS:251 JACKSON AVENUETELEPHONE:
(650) 368-2383
CITY:REDWOOD CITYSTATE: CAZIP CODE:
94062
CAPACITY: 12CENSUS: 9DATE:
12/28/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Sayoko YoshimuraTIME COMPLETED:
05:00 PM
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On December 28, 2021, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced annual infection control inspection. Upon arrival, LPA observed signage on the front door. LPA was greeted by the Program Director, Sayoko Yoshimura, and Assistant Director, Kendra Ceccato, joined shortly thereafter. LPA explained the purpose of the visit. LPA was screened at the entry point. Program Director, was able to provide LPA with visitor screening documentation.

LPA toured facility and grounds. No accessible bodies of water or fire safety hazards observed. Infection control practices present: face coverings, resident and staff screening and temperature log, COVID-19 signage, and 30-day PPE supply. Dining area was observed to have chairs 6ft apart from each other maintaining social distancing. Bathrooms were observed to be equipped with liquid hand soap and paper-towels. LPA observed only some bathrooms with hand-washing signs. LPA advised Program Director to put hand-washing signage in all bathrooms and make sure the bathrooms have trash cans that are covered. LPA observed the signage posted throughout the facility and recommends putting more reminder signage; masking, cough etiquette, and social distancing.

Medications, toxins and sharps are stored appropriately and inaccessible to residents, and a comfortable temperature is maintained, lighting is sufficient for comfort. Extra linen supply was observed to be adequate. LPA observed sufficient amount of perishable and non-perishable foods.

There are 9 bedrooms in the facility; 3 semi-shared rooms observed with beds 6ft apart and 6 single rooms. First aid kid was observed to be present and completed. According to the Program Director, all staff and residents are vaccinated.

LPA requests the following forms to be sent to CCLD by 1/4/2021:
  • LIC309 Administrative Organization
  • LIC308 Designation of Administrative Responsibility
  • LIC500 Personnel Report
  • Administrator Certificate
  • LIC610E Emergency Disaster Plan

Report is reviewed with Sayoko Yoshimura and Kendra Ceccato and a copy is provided.
SUPERVISORS NAME: Julio Montes
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE: DATE: 12/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/28/2021
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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