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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600912
Report Date: 09/08/2023
Date Signed: 09/08/2023 05:55:54 PM


Document Has Been Signed on 09/08/2023 05:55 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:DELIA'S RETIREMENT HOME, INCFACILITY NUMBER:
415600912
ADMINISTRATOR:CHUA, DELIA J.FACILITY TYPE:
740
ADDRESS:52 ARLINGTON DRIVETELEPHONE:
(650) 757-1768
CITY:SOUTH SAN FRANCISCOSTATE: CAZIP CODE:
94080
CAPACITY:6CENSUS: 4DATE:
09/08/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:56 PM
MET WITH:Delia ChuaTIME COMPLETED:
06:00 PM
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On 9/8/23 LPA Grace Donato made an unannounced annual visit to the facility. LPA met with Licensee/Administrator Delia Chua. LPA explained the purpose of the visit.

LPA toured the facility inside and outside including all of resident rooms, common areas, kitchen area & garage. The indoor and outdoor passageways were free of obstruction. LPA observed some residents were in the living room watching tv and doing some activities. While touring the facility it was observed that the room temperature was at 72 deg F. Hot water was also tested in the bathrooms and the temperature was 105 deg F. The residents have adequate amount of linens and incontinence care items. All personal belongings are intact. Carbon monoxide monitors are working properly. All fire extinguishers have been checked and current. Resident bedrooms and bathrooms were observed to be in good repair equipped with grab bars and non-skid floor. LPA checked the food supply and there is adequate amount of food, 2 days for perishables and & 7 days non-perishable. Emergency drills are logged and done every quarter.

Four resident records and three staff records were reviewed. Resident records are updated, complete and signed. Staff records are complete, with training logs that have met the basic 20hr requirement. Facility has a certified administrator on site with complete certification and training requirements, just waiting for an updated certificate. Facility accepts hospice residents and are in compliance with the required waiver requirements. LPA attempted to interview 2 residents and 1 staff member.

Medication review was done, and all medications are accounted for, and centrally stored medication records are updated.

LPA requested licensee to submit the following and was received in the facility at 9/8/23: LIC 308, Facility Sketch, Liability Insurance.

No deficiencies are cited at this time. Report is reviewed with Licensee and a copy is provided.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Grace DonatoTELEPHONE: (714) 293-8294
LICENSING EVALUATOR SIGNATURE:
DATE: 09/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/08/2023
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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