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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601142
Report Date: 12/21/2023
Date Signed: 12/21/2023 12:41:10 PM

Document Has Been Signed on 12/21/2023 12:41 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:ADAMS PAUL INCFACILITY NUMBER:
415601142
ADMINISTRATOR:DIONSON, ROMMELFACILITY TYPE:
740
ADDRESS:1778 ADAMS STREETTELEPHONE:
(650) 522-8108
CITY:SAN MATEOSTATE: CAZIP CODE:
94403
CAPACITY: 6CENSUS: 6DATE:
12/21/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Rommel Dionson and Rosemarie VeridianoTIME COMPLETED:
12:45 PM
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LPA Jeung conducted follow-up pre-licensing inspection to confirm completion of items referenced on initial pre-licensing visit of 11/30/23.

The following items are observed:

1. Emergency Disaster Plan (LIC610E) is complete and includes phone number for ambulance service and location of 2 fire extinguishers (on page 3 of LIC610E). Utility shut off locations is clearly stated.
(CCR 87465 Incidental Medical and Dental Care)
2. Toilet and shower grab bars are installed in front bathroom (CCR 87303 Maintenance and Operation)
3. There is a designated area for posting information related to family councils. (HSC 1569.158)
4. Spare set of all keys for facility vehicles, facility exits, and cupboards, cabinets is available in the key cabinet in the event of an emergency. (HSC 1569.695)
5. Half bed rails are used for 4 residents, and half rail is positioned at the head of the bed. (CCR 87608 Postural Supports)

As per on-site review of residents during initial pre-licensing visit by CCLD RN consultants, all are deemed appropriate for care in a RCFE, with nursing care specified in each client's Needs and Services Plan, MD approved care plans, and pending exceptions.

Facility meets physical plant requirements for licensure as RCFE for 6 non-ambulatory elderly persons. Immediate licensure is recommended, pending approval of Centralized Applications Bureau.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Audrey Jeung
LICENSING EVALUATOR SIGNATURE: DATE: 12/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/21/2023
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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