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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600911
Report Date: 02/08/2023
Date Signed: 02/08/2023 11:42:50 AM

Document Has Been Signed on 02/08/2023 11:42 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
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:ANGEL HAVENFACILITY NUMBER:
415600911
ADMINISTRATOR:GIUSTO, FERLENEFACILITY TYPE:
740
ADDRESS:1660 WOLFE DRIVETELEPHONE:
(650) 458-6166
CITY:SAN MATEOSTATE: CAZIP CODE:
94402
CAPACITY: 6CENSUS: 4DATE:
02/08/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Administrator, Ferlene GiustoTIME COMPLETED:
11:50 AM
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On February 8, 2023, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced annual infection control inspection. Upon arrival, LPA observed the COVID-19 signage posted at the front entrance. LPA met with Caregiver, Joel Quizon and Administrator, Ferlene Giusto joined shortly thereafter. LPA explained the purpose of the visit and was screened at entry point.

LPA toured the facility and grounds. No accessible bodies of water or fire safety hazards observed. This is a single story home with 6 resident bedrooms, 1 staff room, and 3 full bathrooms. LPA toured the facility with the Caregiver and observed living room and dining room to be clean and free from any tripping hazards. A comfortable temperature of 70 degrees F is maintained and lighting is sufficient for comfort. LPA observed all 6 resident rooms to be private rooms. There are currently two vacant rooms at the facility. LPA toured the full bathrooms and observed it to be equipped with liquid soap, paper towels, hand-washing signs, trash cans with fitted lids and non-skid mats. Bathrooms were observed to be in good repair. Extra linen was present and first aid kit was observed to be completed.

LPA toured the kitchen and observed 2 day perishable and 7 day non-perishable. Sharps and medications were observed to be locked and inaccessible to residents. LPA toured the garage and observed chemicals and toxins to be locked. In addition, LPA observed washer and dryer to be in good working condition and observed extra food supply present. 30-day PPE supply was present. Staff room was observed to be clean and inaccessible to residents. During the visit, LPA observed all staff to have a face covering.

Infection control practices are observed: entry procedures, daily monitoring log for staff, residents and visitors, 30-day PPE supply, face coverings for staff, containment strategies, staff training and policies.

No citations are issued during this visit. Report is reviewed with Administrator and a copy is provided.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE: DATE: 02/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/08/2023
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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