415601011-9-23-2023-14-AS-VBRN-CVXRLT-20230923130739

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 415601011
Report Date: 09/23/2023
Date Signed: 09/23/2023 01:07:44 PM

Document Has Been Signed on 09/23/2023 01:07 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME:	ALLIANCE CARE HOME		FACILITY NUMBER:	415601011
ADMINISTRATOR:	MONTIEL, ALDO		FACILITY TYPE:	735
ADDRESS:	935 FOOTHILL DRIVE		TELEPHONE:	(415) 606-3215
CITY:	DALY CITY	STATE: CA	ZIP CODE:	94015
CAPACITY: 4		CENSUS: 4	DATE:	09/23/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Annette Peig Administrator		TIME COMPLETED:	01:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to conduct a Required - 1 Year visit on 9/23/23 at 9:15AM. The Administrator Certificate was observed for Annette Peig which expired 10/9/23. However, the certificate renewal documents and payment has been submitted to Community Care Licensing (CCL) and the Administrator Certificate Section (ACS) Applications Pending List was observed by LPA during this visit. The facility phone number has been changed to 650-993-8142. LPA met with Annette Peig Administrator and stated the purpose of the visit. LPA observed a printout of the active Administrator Certificate Holders which included Aldo Montiel which expires 6/18/2024. However, Administrator has not received the certificate yet. The facility is licensed for a capacity of 4 non-ambulatory residents of which 4 maybe bedridden. Infection Control Plan observed and submitted to Community Care Licensing (CCL). LPA observed 3 residents participating in individual activities and 1 resident out in community during this visit. LPA observed and conversed with 1 resident during this visit. LPA toured and inspected the physical plant inside and outside to ensure there are no safety hazards to residents. LPA observed a posted updated Liability insurance policy. The most recent emergency drill was 5/2/23.

SUPERVISORS NAME: Victoria Brown
LICENSING EVALUATOR NAME: Victoria Brown
LICENSING EVALUATOR SIGNATURE:	DATE: 09/23/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2023

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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: ALLIANCE CARE HOME	FACILITY NUMBER: 415601011
	VISIT DATE: 09/23/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

LPA observed 2-day perishables and 7-day non-perishables.

The temperature inside the facility was observed to be at 72 *F which is within the required range of 68-85*F. The hot water temperature was measured at 110.3 *F which is within the required range of 105-120*F.

LPA observed fire extinguisher(s), smoke and carbon monoxide detectors, and central heating and air in the facility.

LPA observed the centrally stored medications area to be locked and inaccessible to residents.

The first aid kit contained the required items such as sterile dressings, bandages, adhesive tape, scissors, tweezers, thermometers, antiseptic solution and guide.

LPA observed 2 staff files and 2 resident files during this visit.

LPA conducted interviews of staff and residents during this visit.

Upon a file review the following items were discussed to be submitted with any changes annually:
Any addendums to Infection Control Plan, Designation of Facility Responsibility (LIC308), Liability Insurance
Personnel Report (LIC500) to include the Administrator presence in the facility, Administrator Certificate-Updated

Per the California Code of Regulations, Title 22, Division 6, Chapter 6, no deficiencies observed or cited. Exit interview held, copy of report given

SUPERVISORS NAME: Victoria Brown
LICENSING EVALUATOR NAME: Victoria Brown
LICENSING EVALUATOR SIGNATURE:	DATE: 09/23/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2023

LIC809 (FAS) - (06/04)

Page: 2 of 2