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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600226
Report Date: 09/18/2024
Date Signed: 09/18/2024 01:20:16 PM

Document Has Been Signed on 09/18/2024 01:20 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:COBB HOMEFACILITY NUMBER:
415600226
ADMINISTRATOR/
DIRECTOR:		MARICEL GALICIAFACILITY TYPE:
735
ADDRESS:1310 COBB STREETTELEPHONE:
(650) 522-9773
CITY:SAN MATEOSTATE: CAZIP CODE:
94401
CAPACITY: 6CENSUS: 6DATE:
09/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Maricel Galicia and Mariquita GutierrezTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
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LPA Audrey Jeung toured facility and grounds, including 4 detached storage sheds and 2 storage cabinets in back and side yards. There are 3 shared client bedrooms--all with exits to outside--2 full bathrooms, a staff room with 2 bunk beds, office, living room, dining/family area, kitchen and 2 car garage, where washer and dryer are located and a sofa used by staff for resting. There are no accessible bodies of water or fire safety hazards observed. Medications, toxins and sharps are stored appropriately and inaccessible to clients. Hot water temperature is tested at 115 degrees in clients' bathroom. Carbon monoxide detector is operational. PPE and first-aid kits are inspected and complete. Hygiene items for general use are maintained. An Emergency Disaster Plan is posted. Criminal record clearances or exemptions for facility staff or other individuals who have client contact are verified, as well as first-aid certification and required records for all caregivers. Client files are reviewed and are complete and medications records are maintained. Maricel Galicia is a certified ARF administrator (x 12/24) that oversees facility operations.

The following licensing forms/information are to be completed and returned to CCL by 9/25/24:

LIC 309 Administrative Organization
Facility Sketch (including dimensions)
Proof of control of property (current signed lease agreement)

The following documents are provided to LPA today:
- Current Personnel Report (LIC 500)
- Updated Emergency Disaster Plan (LIC 610, 9 pages, signed and dated)
- Proof of current surety bonding
- Infection Control Plan (LIC9282)

Deficiencies of the General and ARF Licensing Regulations, of the California Code of Regulations, Title 22, Division 6, are cited.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Audrey Jeung
LICENSING EVALUATOR SIGNATURE: DATE: 09/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/18/2024
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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Document Has Been Signed on 09/18/2024 01:20 PM - It Cannot Be Edited


Created By: Audrey Jeung On 09/18/2024 at 12:35 PM
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: COBB HOME
FACILITY NUMBER: 415600226

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85087(a)(3)(A)
BUILDINGS AND GROUNDS
No room commonly used for other purposes shall be used as a bedroom for any person.
Such rooms shall include but not be limited to halls, stairways, unfinished attics or basements, garages, storage areas, and sheds, or similar detached buildings.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above, as detached storage shed is used by staff for sleeping, which poses a potential health, safety or personal rights risk to persons in care.
Male staff #4 is observed in storage shed, where there is a folding lounge chair, pad, bedding, and personal clothing and furnishings.
POC Due Date: 09/20/2024
Plan of Correction
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Plan/proof of correction to be sent to CCLD BY DUE DATE, describing how storage shed will not be used to accommodate staff.
Type B
Section Cited
CCR
80065(g)(1)
PERSONNEL REQUIREMENTS
Good physical health shall be verified by a health screening, including a test for tuberculosis, performed by or under the supervision of a physician not more than one year prior to or seven days after employment or licensure.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on staff records review, the licensee did not comply with the section cited above in 1 out of 6 staff files reviewed, which poses a potential health, safety or personal rights risk to persons in care.
Staff #4 does not have health screening and TB test result on file.
POC Due Date: 09/25/2024
Plan of Correction
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Copy of health screening and TB test result for staff #4 to be sent to CCLD BY DUE DATE.
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:April Cowan
LICENSING EVALUATOR NAME:Audrey Jeung
LICENSING EVALUATOR SIGNATURE:
DATE: 09/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/18/2024


LIC809 (FAS) - (06/04)
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