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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601063
Report Date: 11/17/2022
Date Signed: 11/17/2022 12:04:26 PM


Document Has Been Signed on 11/17/2022 12:04 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:MISSION WOODSIDEFACILITY NUMBER:
415601063
ADMINISTRATOR:CONDE, GABRIEL V.FACILITY TYPE:
740
ADDRESS:2028 MARYLAND STREETTELEPHONE:
(650) 554-1000
CITY:REDWOOD CITYSTATE: CAZIP CODE:
94061
CAPACITY:6CENSUS: 3DATE:
11/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Laura Paniagua TIME COMPLETED:
12:10 PM
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On this day Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced annual inspection visit focused on infection control. LPA met with caregiver Laura Paniagua and explained purpose of today's visit. Per the caregiver the administrator is now Stephanie Gaspar.

LPA the toured facility's building and grounds. 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. PPE supply is observed as in place. Medications, toxins and sharps are stored appropriately and inaccessible to clients. Facility ambient temperature is comfortable. Facility lighting is sufficient for residents and staff safety. Toilet and bathing facilities are equipped properly. Water temperature is tested at 118F in resident's room bathroom. All resident rooms are equipped with private bathrooms. Non-slip mats and grab bars are present. Liquid soap is available and paper towels. Family and residents have access to hand sanitizers if needed. First-aid kit is inspected and complete. A Disaster and Mass Casualty Plan is posted. There are 3 residents and 2 staff on site. Staff is observed wearing masks. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed as current. Facility does not handle resident monies. Fire extinguishers are observed as being inspected on 09/18/2022. Of the extinguishers observed all are charged and ready for use. Administrator certificate is current expiring 03/19/2024.

The following updated forms are requested to be submitted to CCLD by 11/24/2022:

• LIC 308 Designation of Administrative Responsibility
• LIC 500 Personnel Report
• LIC 610E Emergency Disaster Plan
• Copy of administrator certificate and requested documents to have the name changed

No citations are issued on this day

Report is reviewed with caregiver Laura Paniagua.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:
DATE: 11/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/17/2022
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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