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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601000
Report Date: 08/25/2023
Date Signed: 08/25/2023 07:55:56 PM


Document Has Been Signed on 08/25/2023 07:55 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:SOLEDAD'S HOMEFACILITY NUMBER:
415601000
ADMINISTRATOR:BELONG, RACHELFACILITY TYPE:
740
ADDRESS:2880 BERKSHIRE DRIVETELEPHONE:
(650) 454-9905
CITY:SAN BRUNOSTATE: CAZIP CODE:
94066
CAPACITY:4CENSUS: 3DATE:
08/25/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Caregiver, Glenda TalaTIME COMPLETED:
12:25 PM
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On August 25, 2023 Licensing Program Analyst(LPA) Murial Han conducted an unannounced annual inspection. LPA was greeted by caregiver, Glenda Tala and LPA explained the purpose of the visit. Caregiver assisted with the initial inspection and when the administrator and house manager arrived at the facility, they took over the rest of the inspection.

LPA toured the facility inside and outside including the bedrooms (4 private rooms), 2 full- bathrooms, kitchen, living and dining rooms. The facility observed to be cleaned, tidy and in good repair. Bedrooms were equipped with the required furniture for residents to use. Bathrooms are equipped with grab bars, and nonskid mats. Facility temperature is comfortable. Hot water temperature was measured at 108-110 degrees F.

Central stored medication, toxins and sharps objects were observed to be locked and inaccessible to residents.

Emergency drills, central stored medication, and staff training records were reviewed.

Food supplies were observed to be adequate.

Facility is equipped with smoke detectors and carbon monoxide detectors. Fire extinguisher was last serviced May 17, 2022.

Staff records were reviewed and contained criminal clearance, first aid / CPR certificate, Job Description, Abuse Statement, Health Screening with TB test result and criminal record statement.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:
DATE: 08/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/25/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: SOLEDAD'S HOME
FACILITY NUMBER: 415601000
VISIT DATE: 08/25/2023
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LPA reviewed resident's files contained resident's identification and emergency information, admission agreement, medical assessment, LIC 602 (Physician Order), Appraisal Needs and Service Plan, GGRC/IPP, etc.

LPA reviewed P & I records for 3 residents, reconciled cash on hand with attached receipts.

During today's inspection, there is 1 resident present and 2 were attending the adult day program.

No deficiency cited today.

This report is reviewed and discussed with the administrator. A copy is provided.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2023
LIC809 (FAS) - (06/04)
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