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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600796
Report Date: 07/08/2022
Date Signed: 07/08/2022 03:44:35 PM


Document Has Been Signed on 07/08/2022 03:44 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:CAPAY HOMEFACILITY NUMBER:
415600796
ADMINISTRATOR:ALYSSA JOY DECANOFACILITY TYPE:
740
ADDRESS:22 CAPAY CIRCLETELEPHONE:
(510) 305-8919
CITY:SOUTH SAN FRANCISCOSTATE: CAZIP CODE:
94080
CAPACITY:4CENSUS: 4DATE:
07/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Joy DecanoTIME COMPLETED:
04:00 PM
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On this day at 1415hrs, Licensing Program Analysts (LPA) Jaime Vado and Kevin Varilla conducted an unannounced infection control annual inspection. LPA met with caregiver Gracita Fermin and explained purpose of today's inspection. Later during the visit the a facility nurse Melvin Manganaan administrator Alyssa Joy Decano arrived at the facility.

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 but not on 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. Residents are non-ambulatory and bathe on a shower bed as residents cannot stand when bathing. Liquid soap is available. Paper towels are present in half bathroom and full bathroom. Water temperature is tested in hallway bathroom at 110F. First-aid kit is inspected and is complete. A disaster and mass casualty plan is present and current. 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. Administrator certificate is viewed as current expiring 4/24/2023. Mitigation plan is reviewed with the administrator. P&I is also audited and appear to be current. Cleaning supplies are observed as locked in facility kitchen and upper storage area in the garage. Laundry machine and dryer observed as functioning. Emergency food supply and PPE are also located in facility garage.

The following updated forms are requested to be submitted to CCLD by 07/15/2022:

• Copy of administrator Certificate
• LIC 308 Designation of Administrative Responsibility
• LIC 500 Personnel Report
• LIC 400 Affidavit Regarding Client Cash Resources


Report is reviewed with administrator.

No deficiencies cited today.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:
DATE: 07/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/08/2022
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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