<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601138
Report Date: 08/04/2022
Date Signed: 08/04/2022 01:27:32 PM

Document Has Been Signed on 08/04/2022 01:27 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:WESTPARK HOMEFACILITY NUMBER:
415601138
ADMINISTRATOR:BARIS, JULIENNEFACILITY TYPE:
735
ADDRESS:1616 ELEANOR DR.TELEPHONE:
(650) 438-2565
CITY:SAN MATEOSTATE: CAZIP CODE:
94402
CAPACITY: 3CENSUS: 0DATE:
08/04/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Administrator, Julienne BarisTIME COMPLETED:
01:45 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On August 4, 2022, Licensing Program Analyst (LPA) Komal Charitra and Kevin Varilla conducted an announced Pre-Licensing inspection. LPA met with Administrator, Julienne Baris and Board of director's member, Alexander Andal. Upon arrival, LPAs observed COVID-19 postings on the front door of the facility. LPAs were screened at entry point and were asked screening questions. LPA observed the COVID screening log for visitors present.

LPAs toured the facility with administrator and observed that all the indoor and the outdoor passageways are free of obstruction. This is a one story facility with 3 resident rooms, 1 staff room, 2 full bathrooms, and 1 office room. The resident rooms, the living room, the kitchen, the bathrooms and the dining room are well maintained and appeared to be in good repair and odor free. LPA observed the office room to have resident and staff records. In addition, the medication cabinet is located in the office room. The medication cabinet was observed to be locked and inaccessible. The living room and the dining room is observed to be comfortable, spacious with adequate furniture.

LPA observed all resident rooms to be private rooms. All rooms are equipped with required furniture. Blinds are observed to be in good working condition, Extra linen supply was present. LPA observed the bathrooms to be equipped with liquid soap, paper towels, hand washing sign, a covered trash can, and non-skid mats. There are sufficient lighting in the hallways. In addition, emergency lights are observed to be in the hallways. LPAs observed the staff room to have a bed present.

The overall facility temperature was measured at 74 degrees Fahrenheit (F). The hot water temperature measured in the kitchen, two bathrooms and shower were at 111-116 degrees F. The refrigerator temperature was measured at 39 degrees F and the freezer was measured at 0 degree F.

LPA toured the kitchen an observed the locked cabinet which will be used to lock sharps. Kitchen was observed to have liquid soap, and paper towels. Food supplies were observed to be adequate. The Carbon Monoxide detectors were present and properly operated. The first aid kit was completed. Fire systems were checked by county fire department on 6/9/22. The outdoor space is observed to be spacious with a covering for shading.

CONT. to 809C
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE: DATE: 08/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/04/2022
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
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: WESTPARK HOME
FACILITY NUMBER: 415601138
VISIT DATE: 08/04/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
The laundry room was located in the garage. The washer and dryer was observed to be in good repair. 30-day PPE supply was present. The toxins and chemicals were locked in the garage and will be inaccessible to residents.

The Activities Calendar was observed to be posted in the living room. The Resident Rights, Emergency Exiting Plan, Ombudsman posting, House Rules, Licensing Complaint Poster and the Resident Rights are posted in the facility hallway. In addition, there are COVID-19 signs posted through-out the facility and in the bathrooms. A working telephone is present.

According to Administrator, the facility will screen residents once a day and staff once a day upon their arrival. There will be one designated entry point. Facility will have random testing for COVID-19 every two weeks.

There were no objects obstructing the emergency shut-offs: water, electricity (all locations are labeled) and gas shut-off stations.

Administrator, Julienne Baris to send Central Application Bureau Analyst a new floor plan since rooms were not labeled on sketch correctly.

Comp III orientation was reviewed with the Administrator on 8/4/22.

Pre-Licensing is now complete. Immediate Licensure is recommended pending final approval from the Central Applications Bureau.

Exit interview conducted with the Administrator, Julienne Baris and a copy of the report was provided.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE:

DATE: 08/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2