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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600801
Report Date: 10/20/2022
Date Signed: 10/20/2022 11:38:02 AM


Document Has Been Signed on 10/20/2022 11:38 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: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: 4DATE:
10/20/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Administrator, Renalin Salvadico and Leandra SalvadorTIME COMPLETED:
11:45 AM
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On October 20, 2022, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced infection control inspection. Upon arrival LPA observed the COVID signage posted at the front door. LPA met with Administrators, Renalin Salvadico and Leandra Salvador, and explained the purpose of the visit. LPA was screened at entry point and Administrator was able to provide LPA 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 2 full bathrooms and 5 bedrooms. LPA observed 4 resident rooms, two of which were private rooms and the other two observed to be shared rooms with beds 6ft apart from each-other. LPA observed staff room. LPA observed 2 full bathrooms equipped with liquid soap, paper-towels, hand washing signs, trash can with covered lid, and non-skid mats. Bathrooms were observed to be clean and odor-free.

Washer and dryer was observed in the hallway to be in good working condition. Extra linen was observed to be present and COVID-19 signage was observed to be posted throughout the facility. LPA toured the dining room and living room and observed it to be clean and clear from tripping hazards. A comfortable temperature is maintained and lighting is sufficient for comfort.

LPA toured the kitchen and observed 2 day perishable and 7 day non-perishable. Sharps, chemicals, and medications were observed to be locked and inaccessible to residents. LPA observed liquid soap and paper-towels present in the kitchen. LPA toured the garage and observed extra food supply and 30-day PPE supply present.

Infection control practices are observed: COVID signage posted throughout the facility, entry procedures, daily monitoring log for staff, residents and visitors, 30-day PPE supply, face coverings for staff, containment strategies, staff training and policies.

No citations will be issued during this visit. Report is reviewed with Administrators and a copy is provided.

LPA requests the following forms to be submitted to CCLD by 10/27/22:
-LIC308 Designation of Administrative Responsibility
-LIC500 Personnel Report
-LIC610E Emergency Disaster Plan
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 10/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/20/2022
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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