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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601053
Report Date: 11/02/2021
Date Signed: 11/02/2021 02:47:37 PM

Document Has Been Signed on 11/02/2021 02:47 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, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:MONROJ HOMEFACILITY NUMBER:
415601053
ADMINISTRATOR:ROJAS, MONAFACILITY TYPE:
735
ADDRESS:451 3RD AVETELEPHONE:
(415) 279-5677
CITY:REDWOOD CITYSTATE: CAZIP CODE:
94063
CAPACITY: 4CENSUS: 4DATE:
11/02/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Mona RojasTIME COMPLETED:
03:30 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
On November 2, 2021, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced annual inspection. LPA observed COVID-19 signs posted by the front entrance. LPA was greeted by the administrator, Mona Rojas and explained the purpose of the visit. LPA was screened at the front entrance and the Administrator was able to provide the daily visitor screening log documentation. LPA also observed the staff screening log and the resident symptom documenting log.

LPA toured facility and grounds. No accessible bodies of water or fire safety hazards observed. Infection control practices are reviewed: entry procedures, staff training and policies, containment strategies, and 30-day PPE supply. Environmental cleaning supplied are adequate. COVID-19 signage is observed to be posted throughout the facility.

LPA observed 4 single bedrooms, all of which are occupied at this time. Both bathrooms are equipped with hand-washing signs, liquid soap, paper towels, non-skid mats, and a trash can with a foot pedal. Dining room table was observed to have chairs spaced out to be following COVID-19 social distancing protocols.

Medications, toxins and sharps are stored appropriately and inaccessible to residents, and a comfortable temperature is maintained, lighting is sufficient for comfort. First aid kit was observed to be completed. 2-day perishable and 7-day nonperishable food supply was present.

According to administrator all staff and residents are fully vaccinated and got their booster shots.

This report is reviewed with the Administrator, and a copy is provided.
SUPERVISORS NAME: Julio Montes
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE: DATE: 11/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/02/2021
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 1