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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600971
Report Date: 11/17/2022
Date Signed: 11/17/2022 11:50:06 AM

Document Has Been Signed on 11/17/2022 11:50 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
Lookup Error,
, CA
FACILITY NAME:NORTH PENINSULA DAY SERVICESFACILITY NUMBER:
415600971
ADMINISTRATOR:MARIBETH LUCEROFACILITY TYPE:
775
ADDRESS:3560 CALLAN BLVDTELEPHONE:
(650) 952-5165
CITY:SOUTH SAN FRANCISCOSTATE: CAZIP CODE:
94080
CAPACITY: 45CENSUS: 7DATE:
11/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Administrator, Maribeth LuceroTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Victoria Bertozzi arrived unannounced to conduct an Annual Required inspection and met with Administrator, Maribeth Lucero. The inspection is focused on the Infection Control procedures and practices of this facility.

LPA was screened upon arrival which included a temperature check and signing in. LPA initiated a walk-through of the facility around 11:00am and observed the following: Facility has COVID-19 posters throughout that included hand washing signs in bathrooms. Facility was a comfortable temperature and exits were free from obstructions. Facility continues to maintain an isolation room. Some clients attend the day program in person but some continue to participate remotely. LPA observed an activity that included both in-person and remote participants. Observed staff had a masks on during this visit. Facility maintains documentation of staff and client daily temperatures.

Staff continue to receive training on infection control and donning and doffing of Personal Protective Equipment (PPE) and have been N95 fit tested. Commonly touched surfaces are disinfected twice per day, once in the morning and once at the end of the day.

Facility has more than a 30 day supply of PPE including but not limited to masks, gowns, and hand sanitizer. Fire extinguishers were last serviced September 2021. Facility contacted their fire extinguisher vendor during this visit. Carbon monoxide detector was tested and operational. Facility has a vendor who monitors and maintains the fire system and the most recent inspection was conducted August, 2022.

Administrator and LPA discussed their Emergency Disaster Plan, Mitigation Plan and Infection Control Plan.

No deficiencies cited during this inspection.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Bertozzi
LICENSING EVALUATOR SIGNATURE: DATE: 11/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/17/2022
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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