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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601107
Report Date: 10/20/2022
Date Signed: 10/20/2022 10:56:34 AM


Document Has Been Signed on 10/20/2022 10:56 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:BAY LEAF ELDERLY CARE HOME LLCFACILITY NUMBER:
415601107
ADMINISTRATOR:AVENA, MAYEANNE GUINOMMAFACILITY TYPE:
740
ADDRESS:1168 LYONS STREETTELEPHONE:
(650) 542-1692
CITY:REDWOOD CITYSTATE: CAZIP CODE:
94061
CAPACITY:6CENSUS: 6DATE:
10/20/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Mayanne AvenaTIME COMPLETED:
11:00 AM
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On this day Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced annual inspection visit. LPA met with licensee Mayanne Avena and explained purpose of today's visit.

LPA conducted a tour of the facility's physical plant and grounds. There are no accessible bodies of water or fire safety hazards are observed. Infection control practices are reviewed: Entry procedures, staff training and policies, resident monitoring, containment strategies, environmental preparation and cleaning. PPE supply is adequate and infection control signs are posted prominently. Medications, toxins and sharps are stored appropriately and inaccessible to clients, a comfortable temperature is being maintained, and lighting is sufficient for comfort and safety. First-aid kit is inspected and complete. 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 reviewed; first-aid training for staff is current. Staff training is current according to administrator. Anna is a certified RCFE administrator (x 08/2022) that oversees facility operations. There is an additional administrator on record who is present today as well, Gabriel Schoof, whose administrator certificate is current (x07/2023). According to licensee she is awaiting to receive administrator course training hours that is scheduled for December 2022. Water temperature is tested at 105F in private resident full bathroom and tested at 115F in common bathroom in main hallway. Bathrooms and shower rooms have grab bars and non-skid mats in showers. PPE is observed as in place in exterior storage building. Fire extinguishers are charged and ready for use last being inspected on 11/29/2021. LPA did observe one fire extinguisher that needs charging but the other fire extinguishers are charged and ready for use. Smoke alarms and carbon monoxide detectors are in place through out. Food supplies are in place. Facility does not handle resident cash resources.

The following updated forms are being requested to be received by 10/27/2022:

• LIC610E Emergency Disaster Plan
• LIC 308 Designation of Administrative Responsibility
• LIC 500 Personnel Report

There are no citations issued during today's inspection. Report is reviewed with licensee Mayanne Avena.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:
DATE: 10/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/20/2022
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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