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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600704
Report Date: 09/01/2022
Date Signed: 09/01/2022 11:45:25 AM


Document Has Been Signed on 09/01/2022 11:45 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:ENCHANTED GARDEN FOR SENIORSFACILITY NUMBER:
415600704
ADMINISTRATOR:GIUSTO, FERLENEFACILITY TYPE:
740
ADDRESS:188 STARLITE DRIVETELEPHONE:
(650) 212-2674
CITY:SAN MATEOSTATE: CAZIP CODE:
94402
CAPACITY:6CENSUS: 6DATE:
09/01/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Caregiver, Lolita FactolerinTIME COMPLETED:
11:50 AM
NARRATIVE
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On September 1, 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 Caregiver/Assistant Administrator, Lolita Factolerin and explained the purpose of the visit. Caregiver was able to provide screening log documentation for residents and staff.

LPA toured the facility and grounds. No accessible bodies of water or fire safety hazards observed. This is a single story home with 6 resident rooms and 1 full bathroom. All resident rooms were observed to be private rooms and 5 resident rooms were observed to have half bathrooms. LPA observed full bathroom to be equipped with liquid soap, paper towels, hand-washing signage, and a trash can with a lid. LPA toured the kitchen and observed toxins, medications, and sharps locked and inaccessible to residents. 2 day perishable and 7 day non-perishable was present.

Infection control practices are reviewed: COVID signage throughout the facility, face coverings, 30-day PPE supply, visitor sign in, and daily monitoring records for staff and residents. LPA toured the living room and dining room and it was clean and odor-free. The living room was clear from any tripping hazards. A comfortable temperate at 72 degrees F was maintained. Lighting was sufficient for comfort. LPA observed the first aid kit to be completed and extra linen to be present.

Washer and dryer was observed in the garage to be in good working condition. 30-day PPE supply and extra food supply was also present in the garage. During the visit, LPA observed a room that was built in the garage that was not indicated on the facility floor plan. According to the Caregiver, this room in the garage is being utilized as a staff room. LPA advised caregiver to have facility administrator submit an updated facility floor sketch as prior facility floor sketch indicated one of the six rooms in the facility was a staff room. In addition, facility floor plan did not show a staff room in the garage.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 09/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/01/2022
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: ENCHANTED GARDEN FOR SENIORS
FACILITY NUMBER: 415600704
VISIT DATE: 09/01/2022
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LPA requests the following forms to be submitted to CCLD by 9/8/22:
  • LIC308 Designation of Administrative Responsibility
  • LIC500 Personnel Report
  • Administrator Certificate
  • LIC610E Emergency Disaster Plan
  • Updated facility floor plan


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.

Report is reviewed with Caregiver and a copy is provided with appeals rights.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 09/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 09/01/2022 11:45 AM - 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: ENCHANTED GARDEN FOR SENIORS
FACILITY NUMBER: 415600704

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/01/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/08/2022
Section Cited

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87305 Alterations to Existing Building or New Facilities: (a) Prior to construction or alterations, all facilities shall obtain a building permit.
Violation of this regulation is not met by:
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Based on observations, facility built a room in the garage that is not indicated on the facility floor plan that was submitted to CCLD. In addition, CCLD was not noified of this alteration which poses a potential health, safety or personal rights risk to persons in care.
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Type B
09/08/2022
Section Cited

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87307(a)(2)Personal Accommodation and Services: (a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. The following provisions shall apply:(2) Resident bedrooms shall be provided which meet, at a minimum, the following requirements:(B) No room commonly used for other purposes shall be used as a sleeping room for any resident. This includes any hall, stairway, unfinished attic, garage storage area, shed or similar detached building.

Violation of this regulation is not met as evidence by:
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Based on observations, the facility staff are utilizing a room in the garage as a staff room which poses a potential health, safety or personal rights risk to persons 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: 09/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/01/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3