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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600927
Report Date: 02/15/2023
Date Signed: 09/05/2023 10:54:53 AM


Document Has Been Signed on 09/05/2023 10:54 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 02/15/2023 05:58 PM

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

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***This is an amended report removing the name of an LPA that did not attend this inspection***

On this day, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced infection control annual inspection. LPAs met with administrator Ricardo Aban and explained purpose of today's inspection. 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. PPE supply is observed as in place. Medications, toxins and sharps are stored appropriately and inaccessible to clients. Facility ambient temperature is warm and 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. First-aid kits are inspected and is complete. A Disaster and Mass Casualty Plan is observed. Residents are observed during today's visit. Staff is observed on all floors wearing masks. Food supplies are also observed as not in place. Two day perishable and one week non-perishable food supplies are observed as in place. Water temperature is taken in room 16 at 120F and in kitchen is measured at 105F. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed. Administrator certificate is viewed as current expiring 03/25/2023. Mitigation plan is reviewed and remains current.

The following updated forms are requested to be submitted to CCLD by 02/22/2023:

• Updated Administrator Certificate
• Updated surety bond with expiration date
• LIC 308 Designation of Administrative Responsibility
• LIC 309 Administrative Organization
• LIC400 Affidavit Regarding Client/Resident Cash Resources
• LIC402 Surety Bond
• LIC 500 Personnel Report
• LIC 610E Emergency Disaster Plan

No citations issued. Report is reviewed with administrator.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:
DATE: 02/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/15/2023
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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