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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600874
Report Date: 01/25/2023
Date Signed: 01/25/2023 12:27:44 PM


Document Has Been Signed on 01/25/2023 12:27 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:BROOKDALE REDWOOD CITYFACILITY NUMBER:
415600874
ADMINISTRATOR:MONICA CERON TAPIAFACILITY TYPE:
740
ADDRESS:485 WOODSIDE RDTELEPHONE:
(650) 366-3900
CITY:REDWOOD CITYSTATE: CAZIP CODE:
94061
CAPACITY:130CENSUS: 72DATE:
01/25/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Monica Ceron TapiaTIME COMPLETED:
12:30 PM
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On this day Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced annual required 1 year inspection visit focused on COVID infection control. LPA met with executive director Monica Ceron Tapia during today's visit and explained the purpose of today's

Upon entry LPA was COVID screened and had temperature taken. LPA did observe COVID some signs posted a the exterior of the facility but LPA suggested to add more. LPA toured facility's building and grounds with Monica and assistant executive director Patty Malera. No accessible bodies of water or fire safety hazards observed. Infection control practices are reviewed: entry procedures, staff training and policies, resident monitoring, containment strategies, environmental preparation and cleaning. Resident and staff daily temperature log is not current but facility has a policy in place to take temperatures of resident's who exhibit cold/flu symptoms. LPA advised on continuing the daily temperature check log of residents. Staff are screened via temperature check and COVID symptoms upon entry to facility. PPE supply is observed as in place in the assistant executive director's office. Medications, toxins and sharps are stored appropriately and inaccessible to clients. Fire extinguishers are observed through out the facility as fully charged. Inspection date noted on one extinguisher on the 3rd floor as inspected on 06/19/2022. Facility has fire sprinklers in place through out the facility. Facility lighting is sufficient for residents and staff safety. Water temperature is tested at 110F in a resident bedroom on the 3rd floor. Non-skid floor or non-skid shower mats are in place in resident rooms. Liquid soap is available and paper towels are available in resident bathrooms. Resident rooms are observed and they are equipped with the required furniture and light fixtures. First-aid kit is complete. A Disaster and Mass Casualty Plan is posted. Staff are observed wearing masks. Criminal record clearances or exemptions for facility staff or other individuals who have client contact is reviewed. Administrator certificate is current. All staff and residents are fully vaccinated and boosted.

Continued on attached LIC809-C
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:
DATE: 01/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/25/2023
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
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: BROOKDALE REDWOOD CITY
FACILITY NUMBER: 415600874
VISIT DATE: 01/25/2023
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Page 2 - Required 1 Year Annual


The following updated forms are requested to be submitted to CCLD by 02/01/2023:

• LIC 308 Designation of Facility Responsibility
• LIC 500 Personnel Report
• LIC 610E Emergency Disaster Plan
• Copy of updated administrator certificate

No citations issued. Report is reviewed with Monica Tapia.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:

DATE: 01/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2