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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600802
Report Date: 10/25/2021
Date Signed: 10/25/2021 12:54:17 PM

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:PRECIOUS CARE HOMEFACILITY NUMBER:
415600802
ADMINISTRATOR:BONIFACIO, JOANNFACILITY TYPE:
740
ADDRESS:904 87TH STREETTELEPHONE:
(650) 992-2878
CITY:DALY CITYSTATE: CAZIP CODE:
94015
CAPACITY:6CENSUS: 4DATE:
10/25/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Jonasandre DizonTIME COMPLETED:
01:30 PM
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On October 25, 2021, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced annual infection. Upon arrival, LPA observed the signage on the front door. LPA was greeted by Caregiver, Jonasandre Dizon and explained the purpose of the visit. LPA was asked for proof of vaccination card before entering the facility. LPA was asked to sign in on the visitor log.

LPA toured facility and grounds. No accessible bodies of water or fire safety hazards observed. Infection control practices are present: entry procedures, face coverings, daily monitoring for residents and staff, and 30-day PPE supply. Bathroom 1 was observed to have bar soap and no paper towels. Bathroom 2 was observed to be equipped with liquid hand soap and paper towels but no hand-washing signage and open trash bins with no lid. LPA advised Caregiver to have hand-washing signs posted in both bathrooms, equip both bathrooms with liquid soap and paper-towels, and to make sure trash cans are covered with a lid.

COVID-19 signage was posted throughout the facility. LPA recommends putting more face covering and social distancing signs in the living room and the hallways. All rooms are single occupied at this time.

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 inspected and complete.

The following documents are requested to be submitted to CCLD by 11/1/2021:
  • Administrator Certificate
  • LIC500 Personnel Report
  • COVID-19 Mitigation Plan
  • LIC308 Designation of Administrative Responsibility
  • LIC610 Emergency Disaster Plan

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

DATE: 10/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2021
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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