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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 419210029
Report Date: 09/26/2023
Date Signed: 09/26/2023 10:05:08 AM

Document Has Been Signed on 09/26/2023 10:05 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:
09/26/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Administrator, Maria NavarroTIME COMPLETED:
10:15 AM
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On September 26, 2023, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced case management visit to follow up on an incident report that was reported to CCL on August 22, 2023. LPA met with Administrator, Maria Navarro and explained the purpose of the visit.

On August 21, 2023, the Licensee reported that Staff 1 (S1) reported to the administrator that he/she forgot to administer Resident 1's (R1's) medication on August 16, 2023. According to S1, Resident 2's (R2's) medication might've been provided to R1 on accident or R2 received his/her routine medication for two days. Poison control was immediately called. R1 and R2's PCP, Psychiatrist and responsible parties were notified.

During the visit, LPA discussed this incident with the administrator. Administrator terminated S1 after the incident. Medication training was conducted on 9/8/2023 and reporting requirement training was conducted on 8/24/2023.

LPA reviewed 6 staff files and observed medication training and reporting requirement training. LPA observed medication training is being conducted every 4 months and reporting requirements training is being conducted every 6 months.

No deficiencies are cited during the visit. Report is reviewed with the administrator and a copy is provided.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE: DATE: 09/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/26/2023
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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