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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600801
Report Date: 11/02/2021
Date Signed: 11/02/2021 11:22:18 AM

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:AMAZING HOMEFACILITY NUMBER:
415600801
ADMINISTRATOR:CONDE, NECIA&SALVADOR,LEANFACILITY TYPE:
740
ADDRESS:17 JODY COURTTELEPHONE:
(650) 286-9698
CITY:SAN MATEOSTATE: CAZIP CODE:
94402
CAPACITY:6CENSUS: 6DATE:
11/02/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Administrator, Necia CondeTIME COMPLETED:
12:00 PM
NARRATIVE
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On November 2, 2021, Licensing Program Analyst (LPA) Komal Charitra, conducted an unannounced annual inspection. Upon arrival, LPA observed COVID-19 signage posted by the entrance. LPA was greeted by the Administrator, Renalin Salvadico and Iress Caguiat, Necia Conde, and Leandra Salvador joined shortly thereafter. LPA Charitra explained the purpose of the visit. LPA was not screened at the front entrance and the Administrator was not able to provide the daily visitor screening log documentation.

LPA toured the facility and grounds. No accessible bodies of water or fire safety hazards observed. Infection control practices are not reviewed: entry procedures, resident and staff daily monitoring records, visitor screening log, and COVID-19 signage throughout facility. LPA discussed the need to add more reminder signs for residents and visitors regarding face covering and social distancing. LPA Charitra will send administrator additional signs to add to facility.

There were two bathrooms observed during the tour; both equipped with liquid hand soap and paper-towels. LPA advised Administrator to cover the trash bins with lids. LPA observed 2 shared rooms with the beds either 6 feet apart or 3 feet apart from head-to-toe
and 2 private rooms. Staff room observed to have 2 beds 3 feet apart head-to-toe. Extra linen was observed to be present. PPE supply and the environmental cleaning supply are adequate.

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. 2-day perishable and 7-day nonperishable food supply was present.

The following forms are requested to be submitted to LPA by 11/9/2021:
-LIC500 Personnel Report
-LIC610E Emergency Disaster Plan
-LIC309 Administrative Organization
-Administrator Certificate

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.

This report is reviewed and discussed with the Administrator; a copy is provided.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2021
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
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: AMAZING HOME
FACILITY NUMBER: 415600801
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/02/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87468.1(a)(2)


This requirement is not met as evidenced by: Facility failed to provide LPA with resident and staff daily monitoring log; Facility failed to provide LPA with a visitor screening log, Facility failed post COVID-19 signage throughout facility.
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care. The facility failed to provide documentation for the daily residents and staff members screening log; the facility failed to provide documentation for the visitor's screening log; the facility failed to post COVID-19 signage in the living room and dining room.
POC Due Date: 11/09/2021
Plan of Correction
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The Administrator and/or designee will review the Department's Provider Information Notices (PINs) regarding the daily COVID-19 screening process for visitors, residents and staff members and start documenting the results of the screening outcomes on a log to indicate that it was done. Administrators will start continuing the logging practices that were taken in the beginning of the pandemic.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 11/02/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/02/2021
LIC809 (FAS) - (06/04)
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