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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 419210057
Report Date: 05/14/2024
Date Signed: 05/14/2024 11:56:55 AM

Document Has Been Signed on 05/14/2024 11:56 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:DALE'S HOMEFACILITY NUMBER:
419210057
ADMINISTRATOR/
DIRECTOR:		MARISA HOGANFACILITY TYPE:
735
ADDRESS:227 ST. FRANCIS STREETTELEPHONE:
(650) 216-6068
CITY:REDWOOD CITYSTATE: CAZIP CODE:
94062
CAPACITY: 4CENSUS: 3DATE:
05/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Caregiver - Alberto LoretoTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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On 05/14/2024, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced infection control annual inspection. LPA met with administrator Maria Navarro and explained purpose of today's inspection.

This is a GGRC facility. Prior to entry LPA observed COVID posting on the front door. LPA was screened appropriately for COVID prior to entry. Temperature was taken at front door. COVID spread prevention signs are placed through out the facility and main gate. Infection control practices are reviewed: entry procedures, staff training and policies, resident monitoring, containment strategies, environmental preparation and cleaning. PPE supply is observed as in place stored in garage. Staff is observed wearing masks through out the facility. Daily resident temperature checks are being conducted as well as staff's. Mitigation and infection control plans are current and being followed.

There are no accessible bodies of water or fire safety hazards observed. Medications, toxins and sharps are stored appropriately and inaccessible to clients. Facility ambient temperature is warm and comfortable, and lighting is sufficient for residents and staff safety. Toilet and bathing facilities are equipped with grab bars and non-skid flooring. Resident rooms observed contain all required furnishings and lighting. Facility has first-aid kit stored in medication closet with additional masks for PPE . A Disaster and Mass Casualty Plan is observed. Food supplies are observed as in place in main kitchen and storage area. Two day perishable and one week non-perishable food supplies are observed as in place. Criminal record clearances or exemptions for facility staff or other individuals who have client contact are current to those present in the facility on this day. Fire extinguishers inspected are current and within operating range. Carbon monoxide and smoke detectors are observed as in place through out the facility. Fire extinguishers last inspected on 04/29/2024. Disaster drills are conducted regularly and documented every 6 months.

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SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Jaime Vado
LICENSING EVALUATOR SIGNATURE: DATE: 05/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/14/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: DALE'S HOME
FACILITY NUMBER: 419210057
VISIT DATE: 05/14/2024
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LPA reviewed one resident file of three residents. LPA also reviewed 3 staff files on this day. All files are current per review made. P&I is handled by the facility and per review of the monies of C1 it is current and logged accurately. Administrator certificate is observed as expired as of 05/10/2024 but the administrator submitted the required recertification items in March of this year.

The following updated forms are requested to be submitted to CCLD by 05/21/2024:

• Updated Administrator Certificate
• Updated surety bond with expiration date
• LIC 308 Designation of Administrative Responsibility
• LIC400 Affidavit Regarding Client/Resident Cash Resources
• LIC402 Surety Bond
• LIC500 Personnel Report
• LIC610E Emergency Disaster Plan
• Copy of current control property

No citations issued. Report is reviewed the administrator .
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Jaime Vado
LICENSING EVALUATOR SIGNATURE:

DATE: 05/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2024
LIC809 (FAS) - (06/04)
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