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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601092
Report Date: 09/15/2022
Date Signed: 09/15/2022 12:15:26 PM

Document Has Been Signed on 09/15/2022 12:15 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:ALEXEI'S HOMEFACILITY NUMBER:
415601092
ADMINISTRATOR:FLORES, VICTORIAFACILITY TYPE:
735
ADDRESS:140 OAKFIELD AVENUETELEPHONE:
(650) 307-3607
CITY:REDWOOD CITYSTATE: CAZIP CODE:
94061
CAPACITY: 3CENSUS: 3DATE:
09/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Victoria FloresTIME COMPLETED:
12:15 PM
NARRATIVE
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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 administrator and let her know the purpose of today's visit. Upon entry LPA had temperature taken and answered COVID protocol questions as well as signing the visitor log book.

LPA toured the physical plant inside and out. There are no accessible bodies of water or fire safety hazards observed. COVID postings are present in dining room but not in hallways where resident rooms are located. Hand sanitizer is observed as readily available through out the facility. Facility ambient temperature is warm and comfortable, and lighting is sufficient for residents and staff safety. Medication cabinet is observed as in order and door is locked. First aid kit is observed as in place in kitchen cabinet. Toilet and bathing facilities are equipped with grab bars and some showers equipped with non-slip mats. Liquid soap is available. Paper towels are present for resident use. Water temperature is taken in both common bathrooms at 116F. LPA observed 3 resident rooms and all had required furniture, lighting, linens and were in clean condition. Laundry machines and dryers are observed as functioning. Emergency food supply, dry goods, and perishables are observed as in place. Communal dining room is observed as in order with COVID postings present. Fire extinguishers are charged ready for use last stamped as inspected on 1/23/2020 but are charged according to dial on the extinguisher.

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 are stored appropriately and inaccessible to clients. LPA reviewed training records and they are current. LPA sampled staff first aid cards and training records and they are current. Resident temperature logs and staff logs are current. All staff and residents are vaccinated according to the administrator. Facility does PCR testing every month. Facility handles client P&I monies. This was audited and is accurate.

A disaster and mass casualty plan is present and current. Criminal record clearances or exemptions for facility staff or other individuals are reviewed. One staff person, Joey Sta Cruz, is not associated. Administrator certificate is viewed as current expiring 05/29/2023. Mitigation plan is reviewed with the administrator and is current. Infection control plan is current.

LPA is requesting the following forms to be updated and sent to the Department by 9/22/2022:

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

Report is reviewed with administrator. Deficiency is cited on this day on attached LIC809D. Cvil Penalty is being assessed today in the amount of $100.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Jaime Vado
LICENSING EVALUATOR SIGNATURE: DATE: 09/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/15/2022
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 2
Document Has Been Signed on 09/15/2022 12:15 PM - It Cannot Be Edited


Created By: Jaime Vado On 09/15/2022 at 11:27 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: ALEXEI'S HOME
FACILITY NUMBER: 415601092

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/15/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/16/2022
Section Cited
CCR
87355(e)(2)

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Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c)
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Administrator shall ensure to submit a criminal record clearance transfer request to the licensing office for S1 by the POC due date. Also submit proof of correction and a written plan outlining how this violation will be avoided in the future to licensing office by due date. Failure to correct this deficiency by due date may result in a civil penalty of $100 per day.
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This requirement was not met as evidenced by: Based on records review, licensee failed to request a transfer of criminal record clearance for S1 which poses an immediate health and safety risk to clients in care. It is confirmed that S1 is not associated to the facility on this day 09/15/2022.
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Immediate civil penalty of $100 is being assessed on this day for S1 totalling $100.

$100 x 1 day x 1 staff = $100

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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Jackie Jin
LICENSING EVALUATOR NAME:Jaime Vado
LICENSING EVALUATOR SIGNATURE:
DATE: 09/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/15/2022


LIC809 (FAS) - (06/04)
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