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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601086
Report Date: 08/25/2022
Date Signed: 08/25/2022 11:18:23 AM

Document Has Been Signed on 08/25/2022 11:18 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:SEQUOIA HOMEFACILITY NUMBER:
415601086
ADMINISTRATOR:FUJII, ROGERFACILITY TYPE:
735
ADDRESS:1499 SEQUOIA AVENUETELEPHONE:
(415) 279-3128
CITY:SAN BRUNOSTATE: CAZIP CODE:
94066
CAPACITY: 4CENSUS: 4DATE:
08/25/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:TIME COMPLETED:
11:15 AM
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On this day Licensing Program Analysts (LPA) Jaime Vado conducted an unannounced infection control annual inspection visit. LPA met with facility LVN and let her know the purpose of today's visit. Upon entry LPA observed COVID postings upon entry to the facility on front door. LPA signed in and had temperature taken.

LPA toured the physical plant inside and out. There are no accessible bodies of water or fire safety hazards observed. COVID postings and hand washing signs are present inside the facility. Hand sanitizer is observed as available through out the facility. Facility ambient temperature is warm and comfortable, and lighting is sufficient for residents and staff safety. Medications are locked and not accessible in a medication cart located in the living area of the facility. First aid kit is observed as in place. Toilet and bathing facilities are equipped with grab bars and non-slip mats. Liquid soap is available. Paper towels are present for resident use. Water temperature is taken in common bathrooms at 120F. Laundry machines and dryers are observed as functioning in facility garage. Emergency food supply, dry goods, and perishables are observed as in place. Fire extinguishers are charged ready for use.

Infection control practices are reviewed: entry procedures, staff training and policies, resident monitoring, containment strategies, environmental preparation and cleaning. Medications, toxins are stored appropriately and inaccessible to clients. LPA reviewed staff records on this day. Resident temperature logs and staff logs are current. LPA reviewed COVID vaccine documentation. All staff and residents are fully vaccinated per the records reviewed.

A disaster and mass casualty plan is present. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been finger print cleared and associated to the facility. Infection control plan and mitigation plan is current. Administrator certificate is observed expiring on 1/1/2023. Facility does not handle P&I monies for clients in care.

LPA is requesting the following updated forms to be sent to the Department by 8/31/22:

• Copy of current administrator Certificates
• LIC 308 Designation of Administrative Responsibility
• LIC 500 Personnel Report
• LIC 610D Emergency Disaster Plan


Report is reviewed with administrator Roger Fuji. No citations issued.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Jaime Vado
LICENSING EVALUATOR SIGNATURE: DATE: 08/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/25/2022
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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