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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600819
Report Date: 08/23/2024
Date Signed: 08/23/2024 11:15:49 AM

Document Has Been Signed on 08/23/2024 11:15 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:NORCAL CARE HOME IIFACILITY NUMBER:
415600819
ADMINISTRATOR/
DIRECTOR:		GHLICHLOO, FATOLLAHFACILITY TYPE:
740
ADDRESS:1706 BORDEN STREETTELEPHONE:
(650) 376-3461
CITY:SAN MATEOSTATE: CAZIP CODE:
94403
CAPACITY: 4CENSUS: 4DATE:
08/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Administrator - Israel WeiTIME VISIT/
INSPECTION COMPLETED:
11:30 AM
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On 08/23/2024, Licensing Program Analyst (LPA) Vado Jaime Vado conducted an unannounced annual required inspection visit. LPA met with administrator Israel Wei and explained the purpose of today's inspection. There are currently no residents in the facility as they are all at day program. This is a GGRC vendorized facility.

This is a single level facility licensed for residents age range of 60 years and over all of which may be non-ambulatory. No residents on hospice or receiving oxygen. The physical plant was toured inside and outside of the facility to ensure the safety of the clients. Cameras are observed to be posted around the outside perimeter of the facility but no cameras are inside according to the administrator Israel. LPA observed the facility kitchen which is clean and observed appliances that are in good repair. Knives are stored and locked in in kitchen drawer adjacent to the stove. Perishable and non-perishable food items are observed as in place. There is an additional refrigerator and freezer in the garage area which carries additional food supplies for resident use. First aid kit is observed as complete with required items. Medications are observed to be locked in the office area in a lockable storage area. LPA observed that there are two fire extinguishers in place inspected on 05/13/2024, smoke detector, carbon monoxide detectors are observed in place through out the facility, and central HVAC. Facility is not equipped with fire sprinklers. PPE is observed to be in place in the garage and in a central hallway outside of a resident room. Laundry area is also observed as fully operational in the garage. Emergency exit routes are observed inside and outside to be free and clear of obstructions. Last emergency/disaster drill was conducted on 06/23/2024 which was an earthquake drill where all clients participated in. Water temperature is being tracked via logs observed posted on the refrigerator in the kitchen. Water temperature was measured at 110F. Cleaning supplies are observed to be locked in beneath the kitchen sink and additional toxins and cleaning supplies are observed to be locked in the garage. Fire panel is in the garage with and inspection date tagged as 06/09/2023.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Jaime Vado
LICENSING EVALUATOR SIGNATURE: DATE: 07/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/24/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: NORCAL CARE HOME II
FACILITY NUMBER: 415600819
VISIT DATE: 08/23/2024
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LPA observed all client rooms and all are observed as clean, free of odors, and contained all the required furniture per regulatory recommendations. Extra resident linen supplies are observed as in place in each clients room stored in appropriate areas. There are two client full bathrooms observed which are in good repair. Shower floors are equipped with non-skid mats. P&I monies are inspected and accurate to the ledger reviewed. Medications and logs are observed today as current. During today's inspection LPA reviewed 4 client files which are current and staff files which are current.

The following updated forms are requested to be submitted to CCLD by 08/30/2024:

• Copy of updated administrator certificates as there are more than one administrator
• Copy of facility's liability insurance
• LIC308 Designation of responsible staff person
• LIC400 Affidavit Regarding Client/Resident Cash Resources
• LIC610E Emergency Disaster Plan
• LIC500 Staff Schedule
• Copy of control of property or copy of lease

No citations issued on this day. Report is reviewed with Israel and a copy is provided on this day.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Jaime Vado
LICENSING EVALUATOR SIGNATURE:

DATE: 08/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2024
LIC809 (FAS) - (06/04)
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