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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600798
Report Date: 08/15/2022
Date Signed: 08/15/2022 02:29:14 PM


Document Has Been Signed on 08/15/2022 02:29 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:CORTEZ HOMEFACILITY NUMBER:
415600798
ADMINISTRATOR:UCOL, ANTOLIN G.FACILITY TYPE:
740
ADDRESS:1799 SHOREVIEW AVENUETELEPHONE:
(650) 375-8972
CITY:SAN MATEOSTATE: CAZIP CODE:
94401
CAPACITY:6CENSUS: 5DATE:
08/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Antolin UcolTIME COMPLETED:
02:45 PM
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On this day Licensing Program Analysts (LPA) Jaime Vado conducted an unannounced infection control annual inspection visit. LPA met with facility administrator and let him know the purpose of today's visit. Upon entry LPA observed COVID postings upon entry to the facility but not on the entrance door. Entrance is around the back of the facility through a backdoor. A fence facing Shoreview Avenue indicates where the front door is located.

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. Hand sanitizer is observed as available through out the facility. Facility ambient temperature is warm and comfortable, and lighting is sufficient for residents and staff safety. Medications are locked and not accessible. First aid kit is observed as in place. Toilet and bathing facilities are equipped with grab bars and non-slip mats. Liquid soap is available. Paper towels are present for resident use. Water temperature is taken on lower level common bathroom at 115F. Laundry machines and dryers are observed as functioning. Emergency food supply, dry goods, and perishables are observed as in place. Fire extinguishers are charged ready for use. Last stamped as inspected on 3/28/22.

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 are stored appropriately and inaccessible to clients. LPA reviewed training records and they are current. LPA sampled staff first aid cards and training records and they are current. Resident temperature logs and staff logs are current. All staff are vaccinated. Clients are fully vaccinated as well.

A disaster and mass casualty plan is present. 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 11/18/2023. Mitigation plan is reviewed with the administrator and is current. Infection control plan is current. Facility P&I for clients are inspected and accurate.

LPA is requesting the following updated forms to be sent to the Department by 8/22/22:

• Copy of administrator Certificate
• LIC 308 Designation of Administrative Responsibility
• LIC 400 Affidavit Regarding Client Cash Resources
• LIC 402 Surety Bond
• LIC 500 Personnel Report
• LIC 610D Emergency Disaster Plan
• LIC 9020 Client Roster

Report is reviewed with administrator. No deficiencies cited today.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:
DATE: 08/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/15/2022
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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