<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601048
Report Date: 01/31/2023
Date Signed: 01/31/2023 11:44:57 AM


Document Has Been Signed on 01/31/2023 11:44 AM - 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: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: 5DATE:
01/31/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Oscar MadrigalTIME COMPLETED:
11:45 AM
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
On this day Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced annual required 1 year inspection visit focused on COVID infection control. LPA met with co-administrator Oscar Madirgal during today's visit and explained the purpose of today's

Upon entry LPA was COVID screened and had temperature taken. LPA did observe COVID some signs posted a the exterior of the facility but LPA suggested to add more. LPA toured facility's building and grounds with Oscar. No accessible bodies of water or fire safety hazards observed. Infection control practices are reviewed: entry procedures, staff training and policies, resident monitoring, containment strategies, environmental preparation and cleaning. Resident and staff daily temperature log is not current but facility has a policy in place to take temperatures of resident's who exhibit cold/flu symptoms. LPA advised on continuing the daily temperature check log of residents. Staff are screened via temperature check and COVID symptoms upon entry to facility. PPE supply is observed as in place in the assistant executive director's office. Medications, toxins and sharps are stored appropriately and inaccessible to clients. LPA discovered in the linen closet Comet and cleaning spray unlocked. Fire extinguishers are observed through out the facility as fully charged. Inspection date noted on a fire extinguisher adjacent to kitchen as inspected on 01/26/2023. Water temperature is tested at 130F in a resident bedroom in common hallway adjacent to a resident's room. Non-skid floor or non-skid shower mats are in place in resident room. Liquid soap is available and paper towels are available. Resident room adjacent to common bathroom is observed and they are equipped with the required furniture and light fixtures. First-aid kit is complete. A Disaster and Mass Casualty Plan is posted. Staff are observed wearing masks. Criminal record clearances or exemptions for facility staff or other individuals who have client contact is reviewed. Administrator certificate is current. All staff and residents are fully vaccinated and boosted.

Continued on attached LIC809-C
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:
DATE: 01/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/31/2023
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 3


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: CAPRA HOUSE CARE HOME
FACILITY NUMBER: 415601048
VISIT DATE: 01/31/2023
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
Page 2 - Required 1 Year Annual


The following updated forms are requested to be submitted to CCLD by 02/07/2023:

• LIC 308 Designation of Facility Responsibility
• LIC 500 Personnel Report
• LIC 610E Emergency Disaster Plan
• Copy of updated administrator certificate

Citations are issued on attached LIC809D. Report is reviewed with administrator Oscar Madrigal.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:

DATE: 01/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 01/31/2023 11:44 AM - It Cannot Be Edited

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: CAPRA HOUSE CARE HOME
FACILITY NUMBER: 415601048

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/31/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/01/2023
Section Cited

1
2
3
4
5
6
7
Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C).
1
2
3
4
5
6
7
Facility shall ensure that the water temperature in the facility meets regulatory standards outlined in Title 22. A written plan is to be recieved by the due date. Additionally a daily temperature and logging of temperature shall be taken for 72 hours. The log shall be received by the department certifying testing and monitoring for this period of time.
8
9
10
11
12
13
14
This regulation is in violation as evicenced by: LPA tested the water temperature in the common bathroom located in hallway adjacent to resident room at 130F.
8
9
10
11
12
13
14
Type A
02/01/2023
Section Cited

1
2
3
4
5
6
7
Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.
1
2
3
4
5
6
7
Facility shall ensure that all cleaning solutions are to be locked an inccessible to clients at all times. During today's inspection staff removed the items and stored in locked area for cleaning solutions.

8
9
10
11
12
13
14
This regulation is in violation as evicenced by: LPA observed cleaning supplies such as Comet and cleaning spray stored unlocked in the linen closet adjacent to a residents room in a common hallway.
8
9
10
11
12
13
14
**POC CLEARED ON THIS DAY**
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: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:
DATE: 01/31/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/31/2023
LIC809 (FAS) - (06/04)
Page: 3 of 3