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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600511
Report Date: 07/11/2022
Date Signed: 07/11/2022 04:07:26 PM


Document Has Been Signed on 07/11/2022 04:07 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
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066



FACILITY NAME:MCCAFFREY'S CARE HOMEFACILITY NUMBER:
415600511
ADMINISTRATOR:MCCARFFREY, WALTER & MARIAFACILITY TYPE:
740
ADDRESS:2381 OLYMPIC DRIVETELEPHONE:
(650) 872-0363
CITY:SOUTH SAN FRANCISCOSTATE: CAZIP CODE:
94080
CAPACITY:6CENSUS: 6DATE:
07/11/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Cherry GonzalesTIME COMPLETED:
04:05 PM
NARRATIVE
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On this day Licensing Program Analysts (LPA) Jaime Vado conducted an unannounced infection control annual inspection. LPA met with caregiver Ramel Concepcion and explained purpose of today's inspection. Around 345pm licensee Cherry Gonzales arrived and met with LPA.

Upon entry LPA temperature was taken but COVID questions were not asked. Questions form was signed by LPA. LPA toured the physical plant inside and out. There are no accessible bodies of water or fire safety hazards observed. COVID postings and hand washing signs are present inside the facility and at the main entrance. Hand sanitizer is observed as readily available through out the facility. 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. Medications, toxins and sharps are stored appropriately and inaccessible to clients. Facility ambient temperature is warm and comfortable, and lighting is sufficient for residents and staff safety. Toilet and bathing facilities are equipped with grab bars and bath floor is textured non-slip flooring. Liquid soap is available an paper towels are present in bathrooms. Water temperature is tested in hallway bathroom at 116F. First-aid kit is inspected and is complete. A disaster and mass casualty plan is present dated 2018. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been finger print cleared and associated to the facility. Emergency food supply and PPE are also located in facility garage. Fire extinguishers are observed and charged ready for use. Last inspected on 5/7/2022. Linens for residents are observed as in place in a hallway closet. All residents and staff are fully vaccinated at this time with booster. First aid cards are inspected. S1 and S2 have expired first aid cards at time of inspection. Administrator certificate is current expiring 4/21/2023.

The following updated forms are requested to be submitted to CCLD by 07/18/2022:

• Copy of administrator certificate
• LIC 308 Designation of Administrative Responsibility
• LIC 500 Personnel Report
• LIC 610E Emergency Disaster Plan
• LIC 9020 Register of Facility Clients

Report is reviewed with licensee Cherry Gonzales.

Deficiency cited on following 809D.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:
DATE: 07/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/11/2022
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 2


Document Has Been Signed on 07/11/2022 04:07 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066


FACILITY NAME: MCCAFFREY'S CARE HOME
FACILITY NUMBER: 415600511

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/11/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/18/2022
Section Cited

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First Aid Requirements. All direct care staff and the facility manager shall have first aid training from persons qualified by agencies including, but not limited to, the American Red Cross.
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This requirement was not met as evidenced by: LPA checked first aid cards for staff and S1 and S2 have expired first aid cards. S1 expiring 7/2/22 and S2 expiring 10/21/2021.
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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: Julio MontesTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:
DATE: 07/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/11/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2