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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 419210029
Report Date: 12/09/2022
Date Signed: 12/09/2022 10:41:20 AM

Document Has Been Signed on 12/09/2022 10:41 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:ZACK'S HOMEFACILITY NUMBER:
419210029
ADMINISTRATOR:MARIA CZARINA NAVARROFACILITY TYPE:
735
ADDRESS:210 CURLEW COURTTELEPHONE:
(650) 638-1300
CITY:FOSTER CITYSTATE: CAZIP CODE:
94404
CAPACITY: 4CENSUS: 4DATE:
12/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Administrator, Maria NavarroTIME COMPLETED:
10:51 AM
NARRATIVE
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On December 9, 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 Caregiver, and Administrator, Maria Navarro joined shortly thereafter. LPA explained the purpose of the visit. Administrator was able to provide LPA 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 resident bedrooms, 1 staff room, and 2 full bathrooms. LPA toured the facility living room and dining room and observed it to be free from tripping hazards. LPA toured the resident rooms and observed 1 shared room with beds 6ft apart from each other and 2 private rooms. LPA observed the full bathroom in the shared room and the other full bathroom in the hallway to be equipped with liquid soap, hand-washing signs, paper-towels and a trash can with a lid. Bathrooms were observed to be clean and in good repair. Extra linen was present and emergency bags were maintained in the facility closet.

LPA observed the COVID-19 signage posted throughout the facility. A comfortable temperate of 72 degrees F maintained and lighting is sufficient for comfort. During the visit, LPA observed 2 residents wearing masks. LPA toured the kitchen and observed medications and sharps stored appropriately and inaccessible to residents. Kitchen was equipped with liquid soap, paper towels, and hand washing signs. LPA observed 7 day non-perishable, however did not observe 2 day perishable. According to the Administrator, the facility staff will go grocery shopping today. LPA toured the garage and observed a washer and dryer in good repair. LPA observed 30-day PPE supply present. Toxins were observed to be locked and stored appropriately and inaccessible to residents.

According to the Administrator, staff are required to take COVID test prior to their shift.

Administrator to submit LIC308- Designation of Administrative Responsibility to CCL by 12/16/22.

Deficiency of the Residential Care Elderly California Code of Regulations, Title 22, Division 6 is observed and cited on a LIC 809D. Failure to correct the deficiencies may result in civil penalties.

Report is reviewed with Administrator and a copy is provided with appeal rights.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE: DATE: 12/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/09/2022
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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Document Has Been Signed on 12/09/2022 10:41 AM - It Cannot Be Edited


Created By: Komal Charitra On 12/09/2022 at 10:16 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: ZACK'S HOME
FACILITY NUMBER: 419210029

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/09/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/10/2022
Section Cited

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85076 Food Service: (d) The licensee shall meet the following food supply and storage requirements: (1) Supplies of ... fresh perishable foods for a minimum of two days shall be maintained on the premises.

Violation of this regulation is evidenced by:
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Based on observation, the facility failed to maintain a two day supply of perishable food on the premises which poses and immediate health and safety risk to residents in care. This is not adequate to meet the needs of 4 residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Cara Smith
LICENSING EVALUATOR NAME:Komal Charitra
LICENSING EVALUATOR SIGNATURE:
DATE: 12/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/09/2022


LIC809 (FAS) - (06/04)
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