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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600686
Report Date: 09/19/2022
Date Signed: 09/19/2022 12:51:33 PM


Document Has Been Signed on 09/19/2022 12:51 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:DAMENIK'S HOMEFACILITY NUMBER:
415600686
ADMINISTRATOR:MONTILLA, DANILO F.FACILITY TYPE:
740
ADDRESS:767 MADDUX DRIVETELEPHONE:
(650) 756-5125
CITY:DALY CITYSTATE: CAZIP CODE:
94015
CAPACITY:6CENSUS: 5DATE:
09/19/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH: Assistant Administrator, Matthew Montilla TIME COMPLETED:
01:00 PM
NARRATIVE
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On September 19, 2022, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced annual infection control inspection. Upon arrival, LPA observed the COVID signage posted at the front entrance. LPA met with Assistant Administrator, Matthew Montilla and explained the purpose of the visit. LPA observed the visitor screening log at entry point and Caregiver was able to provide screening log documentation for staff and residents.

LPA toured the facility and grounds. No accessible bodies of water or fire safety hazards observed. This is a single story home with 5 resident bedrooms, 2 full bathrooms, 1 half bathroom and 1 staff room. LPA toured all resident bedrooms; 4 were observed to be private and 1 was observed to be shared with beds 6ft apart from each other. LPA observed 2 full bathrooms, and one half bath. All bathrooms were observed to be clean, odor free and were equipped with liquid soap, paper-towels, hand washing sign, trash can with a tight fitted lids, and non-skid mats. LPA observed staff room.

LPA toured the dining room and living room to be clear from any tripping hazards. A comfortable temperature is maintained and lighting is sufficient for comfort. LPA observed the first aid kit and medications locked and stored appropriately and inaccessible to residents. LPA toured the kitchen and observed 2 day perishable and 7 day non-perishable. Sharps, toxins, and chemicals were locked and stored away and inaccessible to residents.
LPA toured the garage and observed washer and dryer in good repair. Extra food supply and 30-day PPE supply was observed to be present. Extra linen was observed to be present.

Infection control practices are reviewed: COVID signage throughout the facility, face coverings, 30-day PPE supply, entry procedures, daily monitoring records for staff, residents and visitor.

CONT. to 809C
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 09/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/19/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: DAMENIK'S HOME
FACILITY NUMBER: 415600686
VISIT DATE: 09/19/2022
NARRATIVE
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During the visit, LPA found that Staff #1 (S1) was not fingerprinted and associated to the facility. LPA Charitra reviewed S1's fingerprint documentation with the Assistant Administrator and observed that S1 does have fingerprint clearance however, is not associated to the facility. Assistant Administrator provided LPA with S1's fingerprint transfer documentation to associate S1 to the facility.

This violation results in a civil penalty of $100.

Deficiency of the Residential Care Elderly California Code of Regulations, Title 22, Division 6 is observed and cited on a LIC 809D. Failure to correct the deficiencies may result in civil penalties.

LPA requests the following forms to be submitted to CCLD by 9/26/22:
  • LIC308 Designation of Administrative Responsibility
  • LIC500 Personnel Report
  • LIC610E Emergency Disaster Plan
  • Administrator Certificate

Report is reviewed with Assistant Administrator and a copy is provided with appeals rights. Civil Penalty is also assessed and given during the visit.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 09/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3
Document Has Been Signed on 09/19/2022 12:51 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
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066


FACILITY NAME: DAMENIK'S HOME
FACILITY NUMBER: 415600686

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/19/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/20/2022
Section Cited

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Criminal Record Clearance: (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c)
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Based on record review, it was found that S1 is fingerprint cleared however, S1 is not associated to the facility. Facility failed to ensure the S1 is associated prior to working which poses an immediate health and safety risk for residents in care.
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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: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 09/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/19/2022
LIC809 (FAS) - (06/04)
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