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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600901
Report Date: 04/13/2022
Date Signed: 04/13/2022 03:41:05 PM


Document Has Been Signed on 04/13/2022 03:41 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
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066



FACILITY NAME:DERRY WAY HOME, INC.FACILITY NUMBER:
415600901
ADMINISTRATOR:KWAI KWONG LIUFACILITY TYPE:
740
ADDRESS:2243 DERRY WAYTELEPHONE:
(650) 219-7930
CITY:SOUTH SAN FRANCISCOSTATE: CAZIP CODE:
94080
CAPACITY:8CENSUS: 4DATE:
04/13/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Yvonne KwokTIME COMPLETED:
04:00 PM
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On this day at 1430 hours, Licensing Program Analysts (LPA) Jaime Vado conducted an unannounced infection control annual required inspection. LPA met with licensee Yvonne Kwok and explained purpose of today's inspection.

LPA toured facility's building and grounds. Upon entry LPA was not screened for COVID with temperature taken and COVID related questions asked. Licensee did disinfect LPA shoe bottoms but did not screen for temperature or ask LPA any COVID screening questions. LPA did not observe any social distancing signs, cough etiquette signs, face covering signs, or COVID symptoms signs inside the facility. LPA is requesting the posting of these signs to go back up in the facility and at the front door. There are no accessible bodies of water or fire safety hazards observed. Infection control practices are reviewed: entry procedures, staff training and policies, resident monitoring and staff monitoring, containment strategies, environmental preparation and cleaning are in place. PPE supply is observed as in place. LPA is recommending additional N95s to be in place in case of COVID outbreak. LPA informed administrator that additional PPE is available from the regional office upon request. Medications and toxins are locked and secured. Facility ambient temperature is comfortable and lighting is sufficient for residents and staff safety. Toilet and bathing facilities are equipped with grab bars and non-skid flooring material. Liquid soap is available in resident bathrooms and paper towels for resident use. Hand washing signs are present in downstairs bathroom but upstairs resident bathroom does not have the hand washing sign. LPA requested a sign to be put in the upstairs bathroom. First-aid kit is inspected as complete. A Disaster and Mass Casualty Plan observed. There are 4 residents and 2 staff present. All staff wearing masks. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed as current. Administrator certificate expires 6/9/2022. All residents and staff are fully vaccinated and with booster. Mitigation plan has been received by CCLD and according to licensee it is current. Facility does not handle cash resources.

The following updated forms are requested to be submitted to CCLD by 04/20/2022:

• LIC 308 Designation of Administrative Responsibility
• LIC 500 Personnel Report
• LIC 610E Emergency Disaster Plan
• LIC 9020 Resident Roster
• Updated copy of administrator certificate

No deficiencies cited. Report is reviewed with Yvonne Kwok.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:
DATE: 04/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/13/2022
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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