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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600425
Report Date: 09/20/2022
Date Signed: 09/20/2022 11:17:10 AM


Document Has Been Signed on 09/20/2022 11:17 AM - 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:C & C CAREHOMEFACILITY NUMBER:
415600425
ADMINISTRATOR:ETHEL AZCUETA-GUMBANFACILITY TYPE:
740
ADDRESS:2700 OAKMONT DRIVETELEPHONE:
(650) 583-3496
CITY:SAN BRUNOSTATE: CAZIP CODE:
94066
CAPACITY:6CENSUS: 6DATE:
09/20/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Administrator, Ethel GumbanTIME COMPLETED:
11:25 AM
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On September 20, 2022, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced annual infection control inspection. Upon arrival, LPA observed the COVID-19 signage posted at the front door. LPA met with Administrator, Ethel Gumban and explained the purpose of the visit. LPA was screened at entry point and LPA observed the visitor sign in sheet. In addition, administrator was able to provide screening log documentation for residents and staff.

LPAs toured the facility and grounds. No accessible bodies of water or fire safety hazards observed. This is a single story home with 4 resident rooms, 2 full baths, one a half bath, and 1 staff room. LPA observed 2 shared resident rooms with beds 6ft apart or 3ft head-to-toe. LPA observed the other 2 resident rooms to be private. LPA observed all bathrooms to be clean and odor free. All bathrooms were equipped with liquid soap, paper-towels, hand washing sign and a trash can with a fitted lid.

LPA toured the living and dining room and observed it to be clean and clear from any tripping hazards. A comfortable temperate at 67 degrees F was maintained. Lighting was sufficient for comfort. Extra linen was observed to be present. LPA observed COVID-19 signage posted throughout the facility. LPA toured the kitchen and observed medication, sharps, and chemicals to be locked and stored appropriately and inaccessible to residents. LPA toured the kitchen and observed 2 day perishable and 7 day non-perishable.

LPA toured the garage with the administrator and observed the door to be locked. Washer and dryer was observed to be in good working condition. LPA observed extra food supply and 30-day PPE supply present. During the visit, LPA observed a dog in the facility. According to the administrator, the dog is one of the resident's dog and it usually stays in the resident's room. LPA observed the dog gate installed on the doorway of the resident's room.

LPA requests the following forms to be submitted to CCLD by 9/27/22:
-LIC308 Designation of Administrative Organization
-LIC500 Personnel Report
-LIC610E Emergency Disaster Plan

No citations are issued during the visit. LPA reviewed report with Administrator and a copy is provided.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 09/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/20/2022
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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