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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601053
Report Date: 11/02/2022
Date Signed: 11/02/2022 10:22:39 AM

Document Has Been Signed on 11/02/2022 10:22 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: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:
11/02/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Licensee, Irene MonteclarTIME COMPLETED:
10:35 AM
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On November 2, 2022 Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced annual infection control inspection. Upon arrival, LPA observed the COVID-19 signage posted at the front entrance. LPA met with House Manager, Nainamaria Bulaong and Licensee, Irene Monteclar joined shortly thereafter. LPA explained the purpose of the visit. Licensee was able to provide LPA with screening log documentation for residents, staff, and visitors.

LPA toured the facility and grounds. No accessible bodies of water or fire safety hazards observed. This is a single story home with 4 resident bedrooms and 2 full bathrooms. LPA observed all resident rooms to be private rooms. Bathrooms were observed to be equipped with hand-washing signs, non-skid mats, and trash cans with fitted lids. According to the Licensee and House manager, the staff are unable to keep liquid soap, paper-towels, and toilet paper in the bathroom due to the resident's behaviors.

LPA observed living room and dining room to be clean and free from any tripping hazards. A comfortable temperature of 65 degrees F is maintained and lighting is sufficient for comfort. COVID-19 signage was posted throughout the facility.

LPA toured the kitchen and observed 2 day perishable and 7 day non-perishable. Sharps were locked and stored inaccessible to residents. Kitchen was observed to be equipped with liquid soap and paper-towels, with hand-washing signs. LPA toured the garage which stays locked at all times. LPA observed washer and dryer to be in good repair. Medication cart was observed to be locked. First aid kit was observed to be completed. Extra food supply was present. 30-day PPE supply was present.

No citations were issued during this visit. LPA reviewed report with Licensee and House Manager and a copy is provided.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE: DATE: 11/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/02/2022
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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