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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600266
Report Date: 09/22/2022
Date Signed: 09/22/2022 01:17:03 PM


Document Has Been Signed on 09/22/2022 01:17 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:ENCINA CARE HOMEFACILITY NUMBER:
415600266
ADMINISTRATOR:PERMITO, MARIA ELENAFACILITY TYPE:
740
ADDRESS:354 ENCINA AVENUETELEPHONE:
(650) 364-1657
CITY:REDWOOD CITYSTATE: CAZIP CODE:
94061
CAPACITY:6CENSUS: 6DATE:
09/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Maria PermitoTIME COMPLETED:
01:20 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 this day Licensing Program Analysts (LPA) Jaime Vado conducted an unannounced infection control annual inspection visit. LPA met with facility licensee know the purpose of today's visit. Upon entry LPAs temperature temperature was taken, signed visitor log, but was not asked screening questions.

LPA toured the physical plant inside and out. There are no accessible bodies of water or fire safety hazards observed. COVID postings are not present at front door and through out the facility. Hand washing signs for residents are not present. Hand sanitizer is observed as readily available through out the facility. Facility ambient temperature is warm and comfortable, and lighting is sufficient for residents and staff safety. Medication closet is observed as locked. First aid kit is observed as in place. Toilet and bathing facilities are equipped with grab bars and some showers equipped with non-slip mats. Liquid soap is available. Paper towels are present for resident use. Water temperature is taken in both common bathrooms at 110F. LPA observed 2 resident rooms and both had required furniture, lighting, linens and were in clean condition. Laundry machines and dryers are observed as functioning. Emergency food supply, dry goods, and perishables are observed as in place. Communal dining are is observed as in order. Fire extinguisher is observed as inspected last on 9/5/2018 and arrow on the extinguisher's pressure dial is in the green.

Infection control practices are reviewed: entry procedures, staff training and policies, resident monitoring, containment strategies, environmental preparation and cleaning. PPE supply is observed as in place. LPA sampled staff first aid cards and are observed as current. Facility is not maintaining a resident or staff daily temperature log. All staff and residents are vaccinated according to the staff person. .

A disaster and mass casualty plan is present and current. Criminal record clearances or exemptions for facility staff or other individuals are reviewed. Administrator certificate is not available for review. According to licensee the mitigation plan and infection control plans are current. Administrator certificate is observed as expiring on 12/19/2023. Facility does not handle resident cash resources per the licensee.

LPA is requesting the following forms to be updated and sent to the Department by 9/26/2022:

• Copy of administrator Certificate
• LIC 308 Designation of Administrative Responsibility
• LIC 500 Personnel Report
• LIC 610E Emergency Disaster Plan

Report is reviewed with licensee.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:
DATE: 09/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/22/2022
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 1