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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601111
Report Date: 09/13/2021
Date Signed: 09/13/2021 12:12:12 PM

Document Has Been Signed on 09/13/2021 12:12 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
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:MANALO'S BOARD & CARE IVFACILITY NUMBER:
415601111
ADMINISTRATOR:MANALO, JOSEFINAFACILITY TYPE:
740
ADDRESS:2595 OAKMONT AVE.TELEPHONE:
(650) 868-1901
CITY:SAN BRUNOSTATE: CAZIP CODE:
94066
CAPACITY: 8CENSUS: 0DATE:
09/13/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Josefina Manalo TIME COMPLETED:
12:30 PM
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Applicant Josefina Manalo has applied for RCFE relocation and capacity increase. Existing facility #415600386 is located at 840 Camaritas Circle, South San Francisco, CA 94080.
LPAs Jeung and Charitra toured facility and grounds of this 9-bed, ground level facility for 8 non-ambulatory residents. All rooms are private, and 5 rooms have exit doors to outside. There is a staff room and 3 full bathrooms. Washer and dryer are located in 2-car garage. There is a ramp surrounding the facility, which provides egress to the street on west side. Facility sketch accurately reflects floor plan. Medications and toxins are secured in locked cabinets in kitchen and bathroom. Food preparation and service items are present, as well as non-perishable canned fruit and protein. Supply of bed and bath linens is observed.
The following items are observed and must be addressed prior to licensure:

1. Infection protocols are not practiced, as LPAs were not COVID screened upon entry. There is no visitor log maintained, COVID screening questions were not asked, and body temperature was not take until LPAs inquired about this.
2. There are no COVID signs posted: cough/sneeze etiquette, reminders to practice social distancing and wear masks.
3. There is no COVID visitation policy posted at front door.
4. There is no PPE supply maintained in facility.
5. There is an insufficient 7-day supply of canned vegetables on premises.
6. Room doors are numbered and referenced in Emergency Disaster Plan (LIC610E), but there are no room numbers on bedroom doors.
7. Plan for Epidemic Outbreak Specific to Covid-19 Mitigation Plan (LIC808) is missing cell phone number of licensee (page 11).

Continued on next page.
SUPERVISORS NAME: Julio Montes
LICENSING EVALUATOR NAME: Audrey Jeung
LICENSING EVALUATOR SIGNATURE: DATE: 09/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/13/2021
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
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: MANALO'S BOARD & CARE IV
FACILITY NUMBER: 415601111
VISIT DATE: 09/13/2021
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8. Emergency Disaster Plan (LIC610E) is incomplete. See LIC9102TV.
9. Extra set of emergency facility keys are not available. See LIC9102TV.
10. Concrete ramp on southeast corner of house needs to be modified so it does not pose tripping hazard. See LIC9102TV.
11. Activity calendar must be posted. See LIC9102TV.

Ms. Manalo to address each item referenced above, and provide proof to LPA prior to licensure.

Facility phone number is 650/273-9103, and must be included on Emergency Disaster Plan (LIC610E).

Ms. Manalo operates 3 other RCFEs in substantial compliance with Title 22 regulations. Therefore, component III orientation is not done today.
SUPERVISORS NAME: Julio Montes
LICENSING EVALUATOR NAME: Audrey Jeung
LICENSING EVALUATOR SIGNATURE:

DATE: 09/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2021
LIC809 (FAS) - (06/04)
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