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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601005
Report Date: 08/31/2022
Date Signed: 08/31/2022 12:06:29 PM

Document Has Been Signed on 08/31/2022 12:06 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:SANDPIPER HOMEFACILITY NUMBER:
415601005
ADMINISTRATOR:ELISEO, ALDRINFACILITY TYPE:
735
ADDRESS:238 SANDPIPER CTTELEPHONE:
(650) 389-6828
CITY:FOSTER CITYSTATE: CAZIP CODE:
94404
CAPACITY: 4CENSUS: 4DATE:
08/31/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Administrator, Aldrin EliseoTIME COMPLETED:
12:15 PM
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On August 4, 2022, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced infection control inspection. LPA knocked on the door 2x but there was no response. LPA observed two cars parked in the driveway. LPA called Administrator, Aldrin Eliseo and he indicated that residents are in their day program and staff are not present at the facility.

On August 31, 2022, Licensing Program Analyst (LPA) Komal Charitra re-attempted to conduct an unannounced infection control inspection visit. LPA met with Administrator, Aldrin Eliseo and explained the purpose of the visit. Upon arrival LPA observed the COVID-19 signage posted at the front entrance and was screened at entry point. Administrator was able to provide LPA with screening log documentation for residents, staff and visitors.

LPA toured facility and grounds. No accessible bodies of water or fire safety hazards observed. This is a single story facility with 4 private resident rooms and 2 full bathrooms. LPA observed both bathrooms to be equipped with liquid soap, paper towels, hand washing signs, and a covered trash can. Infection control practices are reviewed: COVID signage throughout the facility, face coverings, 30-day PPE supply, entry procedures, daily monitoring records for staff, residents and visitor.

LPA toured the living room and dining room and it was clear and odor-free. The living room was clear from any tripping hazards. A comfortable temperate was maintained and lighting is sufficient for comfort. LPA toured the kitchen and medications, toxins and sharps are stored appropriately and inaccessible to residents. Kitchen was equipped with liquid soap, paper towels, and hand washing signs. LPA observed 2 day perishable and 7 day non-perishable.

LPA observed the garage to have a working washer and dryer. Due to the COVID protocols, the facility has dedicated the garage to be the main entrance for all staff, visitors, and residents. LPA observed the locked toxins and chemicals in the garage and the extra food supply. According to the facility administrator, the facility conducts random COVID testing for staff and response testing for residents.

LPA requests the following forms to be sent to CCLD by 8/7/22:
  • LIC500 Personnel Report
  • LIC400 Resident Cash Resources
  • Administrator Certificate


No citations issued. Report is reviewed with Administrator, Aldrin Eliseo and a copy is provided.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE: DATE: 08/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/04/2022
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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