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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601005
Report Date: 07/23/2021
Date Signed: 07/23/2021 04:14:57 PM

Document Has Been Signed on 07/23/2021 04:14 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
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
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:
07/23/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:51 AM
MET WITH:Aldrin EliseoTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Gladys Kuizon conducted an annual inspection today and met with Administrator Aldrin Eliseo.

At 11:55 AM, LPA entered the facility through the facility's central entry point and was screened by staff. At 12:00 PM, a tour of the facility was conducted. COVID-19 postings were observed. Staff were observed wearing face coverings. Residents were observed having lunch in the communal dining room and watching TV in the living room after their meal. 4 residents and 3 staff were present during inspection.

The facility has at least 30 days' supply of personal protective equipment (PPE). Hand sanitizers, soap, and paper supplies were observed available. At least 2 days' supply of perishable foods and at least 1 week's supply of non-perishable foods are available in the premises. Medications were observed locked and accessible only to staff. Disinfectant supplies were available.

According to Administrator, the facility has achieved 100% vaccination rate against COVID-19 for both residents and staff. The facility is currently accepting visitors inside the facility.

The facility's mitigation plan was received by Community Care Licensing. Based on today's inspection, LPA advised licensee to:
1. Update facility's "No Visitors" policy posted on the entrance door to appropriately reflect the facility's current visitation policy.

No deficiencies were cited. Exit interview conducted with Administrator and a copy of this report was provided during visit.
SUPERVISORS NAME: George Nwafor
LICENSING EVALUATOR NAME: Gladys Kuizon
LICENSING EVALUATOR SIGNATURE: DATE: 07/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/23/2021
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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