<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600892
Report Date: 10/21/2022
Date Signed: 10/21/2022 04:22:14 PM

Document Has Been Signed on 10/21/2022 04:22 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:LYNBROOK HOMEFACILITY NUMBER:
415600892
ADMINISTRATOR:REYES, MARIA THEREZA G.FACILITY TYPE:
735
ADDRESS:496 LYNBROOK DRIVETELEPHONE:
(650) 898-8810
CITY:PACIFICASTATE: CAZIP CODE:
94044
CAPACITY: 6CENSUS: 6DATE:
10/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Caregiver, Elizabeth GacesTIME COMPLETED:
12:10 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 10/21/22, Licensing Program Analyst(LPA) Murial Han conducted an unannounced annual inspection. LPA observed COVID-19 signs posted by the entrance. LPA was greeted by the Lead Staff, Elizabeth Gaces who call the administrator informing LPA's visit. LPA explained the purpose of the visit.

LPA toured facility and grounds. The facility appeared clean and tidy. No accessible bodies of water or fire safety hazards observed. Infection control practices are reviewed: entry procedures, resident and staff daily monitoring records, containment strategies.

During the visit, there were 3 clients and 3 facility staff present. LPA observed 2 clients were actively walking around the facility with their one on one caregivers, and the 3rd client was lying in bed. The facility staff reported the 3 other residents are attending day program.
This is a single level facility with 3 shared rooms, and the beds are observed to be 6" apart. PPE supply and the environmental cleaning supply are adequate, and locked. The bathrooms are equipped with liquid soap and paper towels. Hand-washing instruction posted by the kitchen sink and LPA recommended to post it in the bathroom sinks as well.

Medications, toxins and sharps are stored appropriately and inaccessible to clients, a comfortable temperature is maintained, lighting is sufficient for comfort and safety and food supply was checked and observed to be sufficient. First-aid kit is inspected and complete.

During today's inspection, LPA requested for a copy of the facility's infection control plan, administrator certification, and LIC 500 to be submitted to CCL by Oct 24, 2022.

No deficiency cited today.

This report is reviewed and discussed with the administrator who arrived toward the end of the inspection.

A copy is provided.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE: DATE: 10/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/21/2022
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 1