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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600658
Report Date: 03/17/2022
Date Signed: 03/17/2022 09:51:47 AM


Document Has Been Signed on 03/17/2022 09:51 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
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066



FACILITY NAME:DAMENIK'S HOMEFACILITY NUMBER:
415600658
ADMINISTRATOR:MONTILLA, DANILO F.FACILITY TYPE:
740
ADDRESS:851 BADEN AVENUETELEPHONE:
(650) 827-1100
CITY:SOUTH SAN FRANCISCOSTATE: CAZIP CODE:
94080
CAPACITY:15CENSUS: DATE:
03/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Assistant Administrator, Matthew MontillaTIME COMPLETED:
10:00 AM
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 March 17, 2022, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced annual infection control inspection. Upon arrival, LPA observed COVID-19 signage on the front door. LPA met with Caregiver, Benilda Briones and Assistant Administrator, Matthew Montilla, joined shortly thereafter. LPA explained the purpose of the visit and was screened at entry point. Assistant Administrator was able to provide screening log documentation for residents, visitors, and staff.

LPA toured facility and grounds. No accessible bodies of water or fire safety hazards observed. Infection control practices are present: entry procedures, daily monitoring for residents and staff, and 30-day PPE supply. LPA observed the bathrooms at the facility. LPA advised Assistant Administrator to make sure all bathrooms have a covered trash bin and that hand/bath towels should not be present in the bathrooms or the kitchen. LPA observed a total of 11 bedrooms at the facility, 3 of which are shared rooms with beds 6ft apart. During the visit LPA observed 6 residents eating breakfast in the dining room and 2 residents in the living room maintaining social distance.

LPA Charitra observed COVID signage throughout the facility but advised Assistant Administrator to post more reminder signage (masking, social distance, and cough etiquette). Medications, toxins and sharps are stored appropriately and inaccessible to residents, and a comfortable temperature is maintained, lighting is sufficient for comfort. First aid kit was observed to be completed. LPA observed the facility elevator to have signage posted both inside and outside.

LPA requests the following forms to be sent to CCLD by 3/24/22:
  • LIC308 Designation of Administrative Responsibility
  • LIC500 Personnel Report
  • LIC610E Emergency Disaster Plan

No citations issued during the visit. LPA reviewed report with Matthew Montilla and a copy is provided.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 03/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/17/2022
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 3