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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601143
Report Date: 04/26/2023
Date Signed: 04/26/2023 11:08:15 AM

Document Has Been Signed on 04/26/2023 11:08 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:DEL MONTE JF INCFACILITY NUMBER:
415601143
ADMINISTRATOR:VERIDIANO, DONNA MARIEFACILITY TYPE:
735
ADDRESS:210 DEL MONTE AVENUETELEPHONE:
(650) 580-2983
CITY:SOUTH SAN FRANCISCOSTATE: CAZIP CODE:
94080
CAPACITY: 6CENSUS: 0DATE:
04/26/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Co-Administrator, Rosemarie VeridianoTIME COMPLETED:
11:15 AM
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On April 26, 2023, Licensing Program Analyst (LPA) Komal Charitra conducted an announced Pre-Licensing Inspection. LPA met with Co-Administrator, Rosemarie Veridiano and Program Coordinator, Rommel Dionson and explained the purpose of the visit. This facility is currently licensed with CDPH as an ICF with 5 residents in care. Upon arrival, LPAs temperature was checked and staff screened for COVID symptoms.

LPA toured facility and grounds. No accessible bodies of water or fire safety hazards observed. LPA observed the indoor and the outdoor passageways are free of obstruction. This is a single level facility. The facility has 4 resident rooms; 2 of which are shared rooms with beds 3ft apart head-to-toe and the other 2 which are private rooms. All bedrooms were equipped with required furniture. LPA observed 2 full bathrooms to be odor-free and in good repair. Non-skid mats were observed to be present. Water temperatures throughout the facility was measured between 105-108 degrees F. LPA observed one staff room which is dedicated for live-in staff.

Living room and dining room was observed to be comfortable, spacious and free from any tripping hazards. Temperature of 72 degrees F is maintained throughout the facility and lighting is sufficient for comfort. LPA toured the kitchen and observed it to be clean and in good repair. The refrigerator was measured at 40 degrees Fahrenheit (F) and the freezer was measured at -5 degrees F. Medication cabinet was observed to be locked in the kitchen and first aid kit was observed to be present and completed. Dry goods/emergency food supplies are stored in the garage. Chemicals and toxins were observed to be in the garage stored appropriately and inaccessible to residents. Washer and dryer was observed in good repair. Extra linen was observed to be present.

All fire prevention systems such as sprinklers, smoke detectors, carbon monoxide detectors, fire extinguishers, and fire control panel have been inspected and approved as of 8/9/2022.

Facility is clean and in good repair based on observations made today. Facility is in compliance with Title 22 regulations. No citations are issued. LPA is recommending licensure of the facility.

Component III is conducted and report is reviewed with Co-Administrator, Rosemarie Veridiano. A copy of report is provided.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE: DATE: 04/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/26/2023
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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