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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 419210027
Report Date: 11/16/2021
Date Signed: 11/16/2021 03:30:49 PM

Document Has Been Signed on 11/16/2021 03:30 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:DAVID'S HOMEFACILITY NUMBER:
419210027
ADMINISTRATOR:VICTOR JOSE ABILLARFACILITY TYPE:
735
ADDRESS:1052 INVERNESS DRIVETELEPHONE:
(650) 593-2396
CITY:SAN CARLOSSTATE: CAZIP CODE:
94070
CAPACITY: 4CENSUS: 3DATE:
11/16/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Administrator, Victor AbillarTIME COMPLETED:
02:45 PM
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On November 16, 2021, Licensing Program Analyst (LPA) Komal Charitra and Steven Chang conducted an unannounced annual inspection. Upon arrival LPAs observed the COVID-19 signage posted at the front door. LPAs was greeted by Administrator, Victor Abillar and explained the purpose of the visit. LPAs were screened at the entry point and the Administrator was able to provide screening log documentation for residents, visitors, and staff.

LPAs toured facility and grounds. No accessible bodies of water or fire safety hazards observed. Infection control practices are present: entry procedures, face coverings, daily monitoring for residents and staff, and 30-day PPE supply. Bathrooms are equipped with hand-washing signage, non-skid mats, liquid soap and paper towels. All trash cans are covered with lids. LPAs observed the COVID-19 signage posted throughout the facility. LPA recommends posting more social distancing signs in the living and dining room.

There are 3 bedrooms at the facility, all of which are occupied at this time. LPAs observed 2 single rooms and one semi-private room, beds 3 feet apart from head-to-toe. LPAs observed 2 day perishable and 7 day non-perishable present.

Medications, toxins and sharps are stored appropriately and inaccessible to residents, and a comfortable temperature is maintained, lighting is sufficient for comfort. First aid kit was observed to be completed. LPA observed the extra linen present.

According to the Administrator all staff and residents are vaccinated and resident have received their booster shots.

LPA requests the following documents to be submitted to CCLD by 11/23/2021:
  • LIC400 Resident Cash Resources
  • LIC309 Administrative Organization
SUPERVISORS NAME: Julio Montes
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE: DATE: 11/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/16/2021
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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