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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 419210027
Report Date: 09/12/2022
Date Signed: 09/12/2022 11:36:37 AM

Document Has Been Signed on 09/12/2022 11:36 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: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: 4DATE:
09/12/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:Administrator, Victor AbillarTIME COMPLETED:
11:45 AM
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On September 12, 2022, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced annual infection control inspection. Upon arrival LPA observed the COVID-19 signage posted at the front entrance. LPA met with Administrator, Victor Abillar and explained the purpose of the visit. Administrator was able to provide screening log documentation for staff, visitors, and residents.

LPA toured facility and grounds. No accessible bodies of water or fire safety hazards observed. This is a single story facility with 3 bedrooms and 2 full bathrooms. LPA toured the facility living room and dining room and observed it to be free from tripping hazards. Two resident rooms were observed to be private rooms and one resident room was observed to be a shared room with beds 6ft apart from each other. LPA toured the bathrooms and observed both bathrooms to be equipped with liquid soap, paper towels, hand washing signs, and a trash can with a fitted lid.

LPA observed the COVID-19 signage posted throughout the facility. A comfortable temperate was maintained and lighting is sufficient for comfort. The facility was odor-free and in good repair. LPA toured the kitchen and observed medications, toxins and sharps are stored appropriately and inaccessible to residents. Kitchen was equipped with liquid soap, paper towels, and hand washing signs. LPA observed 2 day perishable and 7 day non-perishable.

LPA observed a working washer and dryer. Extra linen and 30-day PPE supply was observed to be present. According to the Administrator, staff screen and test themselves with antigen test kits the beginning of each shift.

LPA requests the following form to be sent to CCLD by 9/19/22:
-LIC308 Designation of Administrative Responsibility

Report is reviewed with Administrator and a copy is provided.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE: DATE: 09/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/01/2022
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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