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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 419200006
Report Date: 05/04/2022
Date Signed: 05/04/2022 05:13:19 PM

Document Has Been Signed on 05/04/2022 05:13 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:GIFT OF LOVEFACILITY NUMBER:
419200006
ADMINISTRATOR:SISTER M.FAUSTINE MCFACILITY TYPE:
736
ADDRESS:160 MILAGRA DRIVETELEPHONE:
(650) 557-0354
CITY:PACIFICASTATE: CAZIP CODE:
94044
CAPACITY: 13CENSUS: 4DATE:
05/04/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Administrator, Sister FaustineTIME COMPLETED:
01:05 PM
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On 5/4/2022 Licensing Program Analyst(LPA) Murial Han conducted an unannounced annual inspection. LPA observed COVID-19 signs posted by the entrance. LPA was greeted by administrator, Sister Faustine. LPA explained the purpose of the visit and LPA was screened at the front entrance where there was a hand washing station, hand sanitizer, COVID-19 signs, and screening log.

LPA toured facility and grounds. No accessible bodies of water or fire safety hazards observed. Infection control practices are reviewed: entry procedures, staff training and policies, resident and staff daily monitoring records, containment strategies. there are 4 residents at the facility and all of them are residing in private rooms. PPE supply and the environmental cleaning supply are adequate, bathrooms are equipped with liquid soap and paper towels, and hand washing instruction is posted by the hand washing stations. All trash cans are observed to have lids. There a COVID-19 signs throughout the facility and there are 2 isolation carts with PPE supplies set up by each hallway.

Medications, toxins and sharps are stored appropriately and inaccessible to resident, a comfortable temperature is maintained, lighting is sufficient for comfort and safety; food supply was checked and observed to be sufficient. First-aid kit is inspected and complete.


No deficiency cited today. This report is reviewed and discussed with the administrator.

A copy is provided.
SUPERVISORS NAME: Julio Montes
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE: DATE: 05/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/04/2022
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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