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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600226
Report Date: 10/31/2022
Date Signed: 10/31/2022 12:07:53 PM

Document Has Been Signed on 10/31/2022 12:07 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:COBB HOMEFACILITY NUMBER:
415600226
ADMINISTRATOR:ESTRELITA S. GERVACIOFACILITY TYPE:
735
ADDRESS:1310 COBB STREETTELEPHONE:
(650) 522-9773
CITY:SAN MATEOSTATE: CAZIP CODE:
94401
CAPACITY: 6CENSUS: 6DATE:
10/31/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Beth FrancoTIME COMPLETED:
12:15 PM
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On this day Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced annual inspection visit. LPA met with licensee Maria Baris and the administrator Beth Franco and explained purpose of today's visit.

LPA conducted a tour of the facility's physical plant and grounds. There are no accessible bodies of water or fire safety hazards are observed. Infection control practices are reviewed: Entry procedures, staff training and policies, resident monitoring, containment strategies, environmental preparation and cleaning. PPE supply is adequate and infection control signs are posted through out facility. Medications, toxins and sharps are stored appropriately and inaccessible to clients, a comfortable temperature is being maintained, and lighting is sufficient for comfort and safety. First-aid kit is inspected and complete. A Disaster and Mass Casualty Plan is present. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed; first-aid training for staff is current. Staff training is current as inspected at random. Beth is the certified administrator (x 09/20/2022) and oversees facility operations. According to Beth she has already submitted renewal of administrator certificate but is awaiting the new certificate to arrive. Water temperature is tested at 108F in a common full bathroom adjacent to main dining table. Bathrooms and shower rooms have grab bars and non-skid mats in showers. Liquid hand soap and paper towels are present along with garbage can with lid. PPE is observed as in place in exterior storage building. Fire extinguishers are charged and ready for use. Smoke alarms and carbon monoxide detectors are in place through out. Food supplies are in place.

The following updated forms are being requested to be received by 11/07/2022:

• LIC610D Emergency Disaster Plan
• LIC 308 Designation of Administrative Responsibility
• LIC 500 Personnel Report
• Updated administrator certificate

There are no citations issued during today's inspection. Report is reviewed with Beth and Maria.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Jaime Vado
LICENSING EVALUATOR SIGNATURE: DATE: 10/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/31/2022
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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