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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601048
Report Date: 02/04/2022
Date Signed: 02/04/2022 06:37:23 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:CAPRA HOUSE CARE HOMEFACILITY NUMBER:
415601048
ADMINISTRATOR:MADRIGAL, PAULAFACILITY TYPE:
740
ADDRESS:779 PARK WAY DRIVETELEPHONE:
(650) 745-8032
CITY:SOUTH SAN FRANCISCOSTATE: CAZIP CODE:
94080
CAPACITY:6CENSUS: 6DATE:
02/04/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
05:30 PM
MET WITH:Oscar MadrigalTIME COMPLETED:
06:45 PM
NARRATIVE
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During complaint investigation visit, LPA Jeung observed a deficiency of the CA Code of Regulations, Title 22, related to COVID infection control.

Deficiency is cited on a following page.

The following information/forms are requested to be submitted to CCLD BY 2/9/22:
- Personnel Report (LIC500)
- Designation of Administrative REsponsibility (LIC308)
- Signed current lease agreement
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:

DATE: 02/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: CAPRA HOUSE CARE HOME
FACILITY NUMBER: 415601048
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/04/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/09/2022
Section Cited

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PERSONAL RIGHTS OF RESIDENTS
Residents in all RCFEs shall have the following personal right:
To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met, as evidenced by absence of any COVID screening of LPA upon arrival to facility.
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Licensee failed to ensure that residents were ensured of COVID safety, as staff did not screen LPA nor ask for her to sign a visitor log, which poses a potential health, safety or personal rights risk to clients in care. Visitor log shall at leaset include responses to COVID screeniing questions, temperature, COVID vaccination verification, & contact number.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:
DATE: 02/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/04/2022
LIC809 (FAS) - (06/04)
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