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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600288
Report Date: 11/02/2022
Date Signed: 11/02/2022 12:06:43 PM

Document Has Been Signed on 11/02/2022 12:06 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:ROSENER HOUSE ADULT DAY SERVICEFACILITY NUMBER:
415600288
ADMINISTRATOR:KALT, BARBARAFACILITY TYPE:
775
ADDRESS:500 ARBOR ROADTELEPHONE:
(650) 322-0126
CITY:MENLO PARKSTATE: CAZIP CODE:
94025
CAPACITY: 80CENSUS: 35DATE:
11/02/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Program Manager, Shanah HawkTIME COMPLETED:
12:15 PM
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On November 2, 2022, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced annual infection control inspection. Upon arrival, LPA observed the COVID-19 signage posted on the front entrance. LPA met with Program Manager, Shanah Hawk and was screened at entry point. Program Manager was able to provide LPA with screening log documentation for clients, staff, and visitors. According to the Program Manager, this is a Monday through Friday program: 9am-2:30pm is the Formal Activity Program and from 2:30pm-4pm is the program's extended hours.

LPA toured the facility and grounds. No accessible bodies of water or fire safety hazards observed. This is a single story building with 4 activity rooms, a dining room, and a kitchen. LPA observed a communal bathroom in the lobby area to be equipped with liquid soap, paper-towels and a hand-washing sign. LPA advised Program Manager to ensure all bathrooms have a trash can with a fitted lid.

During the visit LPA observed 2 main bathrooms; female and male with multiple stalls and 2 additional private bathrooms. The bathroom was clean and odor free. Bathrooms were equipped with liquid soap, paper-towels, and hand-washing signs. LPA observed the dining room to have tables 6ft apart from each other. LPA observed the kitchen to be locked. According to the Program Manager, the kitchen door stays locked at all times, however clients have access to the fridge with staff's assistance. Sharps and toxins were stored appropriately and inaccessible to clients. LPA observed the clients in the activity room to be maintaining social distancing and wearing a face covering. LPA observed a total of 4 activity rooms. Clients were observed in the art room to be seated 6ft apart from each other. LPA observed day program's office space and observed the nurse's office. According to the Program Manager, the day program assists clients with their medications and it is stored in the nurse's room. LPA observed the nurse's room and observed first aid kit to be present and medications to be locked. LPA observed 30-day PPE supply present and all staff members were observed to have a face covering.

LPA requests the following forms to be submitted to CCLD by 11/9/22:
-LIC308 Designation of Administrative Responsibility
-LIC500 Personnel Report
-LIC610E Emergency Disaster Plan

No citation issued during this visit. LPA reviewed report with Program Manager and a copy is provided.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE: DATE: 11/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/02/2022
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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