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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601048
Report Date: 09/05/2023
Date Signed: 09/05/2023 12:54:27 PM


Document Has Been Signed on 09/05/2023 12:54 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: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:
09/05/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:36 AM
MET WITH:Macrina Brooks & Oscar MadrigalTIME COMPLETED:
01:30 PM
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On 9/5/2023, Licensing Program Analyst (LPA) Grace Donato conducted an unannounced case management visit to follow up on an incident that was reported to CCLD on 9/5/2023. LPA met with Caregiver Macrina Brooks and Administrator Oscar Madrigal followed after explained the purpose of the visit.

CCLD received a report regarding the family member (FM) of a resident (R1) claiming abuse because of R1 had a small skin tear on his/her right hand. FM also gets angry when facility receives a stop order for medication stating that only FM can make decisions for R1's medications.

LPA has obtained pertinent documents regarding the issue for review. Waiting for additional document to be available in the facility and then to be emailed to LPA.

No deficiency cited during today's visit.

This report was reviewed and copy has been provided.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Grace DonatoTELEPHONE: (714) 293-8294
LICENSING EVALUATOR SIGNATURE:
DATE: 09/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/05/2023
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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