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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600616
Report Date: 03/10/2022
Date Signed: 03/10/2022 06:07:41 PM


Document Has Been Signed on 03/10/2022 06:07 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:NEW CEDAR LANE CARE HOME, INC.FACILITY NUMBER:
415600616
ADMINISTRATOR:DIAZ, YOLANDAFACILITY TYPE:
740
ADDRESS:924 CEDAR STREETTELEPHONE:
(650) 728-3132
CITY:MONTARASTATE: CAZIP CODE:
94037
CAPACITY:17CENSUS: 17DATE:
03/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Administrative Manager, Georgina AguirreTIME COMPLETED:
11:40 PM
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On 3/10/22, Licensing Program Analyst(LPA) Murial Han conducted an unannounced annual inspection. LPA observed COVID-19 signs posted by the entrance. LPA was greeted the administrative manager, Gerogina Aguirre. LPA explained the purpose of the visit and LPA was screened at the front entrance.

LPA toured facility and grounds. No accessible bodies of water or fire safety hazards observed. Infection control practices are reviewed: entry procedures, staff training and policies, resident and staff daily monitoring records, containment strategies, PPE supply and the environmental cleaning supply are adequate; bathrooms are equipped with soap and paper towels, hand washing instruction is posted by the hand washing stations. Trash cans are observed to have foot operated lids. The facility has 2-bed rooms and private rooms. The beds in the 2-bed rooms are observed to be 6" apart from each other. The facility has 2 ready-to-go isolation carts set-up with PPE supplies.

Medications and chemicals are observed to be locked in a storage room with a digital lock. Sharps are stored appropriately and inaccessible to residents in the kitchen with a lock on the door and staff locks the door when he/she leaves the kitchen. LPA Han recommended to lock the drawer that stores the sharps inside the kitchen in addition to the lock on the door. A comfortable temperature is maintained, lighting is sufficient for comfort and safety and food supply was checked and observed to be sufficient. First-aid kits are inspected and complete. There are 17 residents, and 5 staff members present during the inspection.

LPA requested for the following documents to be submitted to CCL by Monday, 3/14/2022
- A copy of the current administrator certification, LIC308 Designation of Administrative Responsibility, LIC402 Surety Bond, Control of Property and LIC610E Emergency Disaster Plan and update the Mitigation Plan LIC808 to reflect the current COVID-19 management process.

No deficiency cited today.
This report is reviewed and discussed with the administrative manager and the administrator who arrived at the end of the inspection. A copy is provided.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:
DATE: 03/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/10/2022
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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