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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 419210065
Report Date: 10/20/2022
Date Signed: 10/20/2022 11:29:13 AM

Document Has Been Signed on 10/20/2022 11:29 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:SABRINA HOMEFACILITY NUMBER:
419210065
ADMINISTRATOR:JAYSON HERNANDEZFACILITY TYPE:
735
ADDRESS:1219 SABRINA COURTTELEPHONE:
(408) 250-2543
CITY:REDWOOD CITYSTATE: CAZIP CODE:
94061
CAPACITY: 3CENSUS: 2DATE:
10/20/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:05 AM
MET WITH:Jayson HernandezTIME COMPLETED:
11:45 AM
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On this day Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced annual inspection visit focused on infection control. LPA met with facility administrator Jayson Hernandez and explained purpose of today's visit.

LPA the toured facility's building and grounds. No accessible bodies of water or fire safety hazards observed. 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. In the garage are additional PPE for facility use. Medications, toxins and sharps are stored appropriately and inaccessible to clients. Facility ambient temperature is comfortable. Facility lighting is sufficient for residents and staff safety. Toilet and bathing facilities are equipped properly. Water temperature is tested at 110F in rear full bathroom. Non-skid mats and grab bars are present. Liquid soap is available. Clients have access to hand sanitizers if needed. First-aid kit is inspected and complete. A Disaster and Mass Casualty Plan is posted. There are 2 clients present and 3 staff including the administrator. Staff present are providing one on one supervision. Staff observed wearing masks. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed as current. Staff first aid cards reviewed are current. Administrator certificate is current expiring 04/14/2024.

The following updated forms are requested to be submitted to CCLD by 10/27/2022:

• Copy of updated administrator certificate
• LIC 308 Designation of Administrative Responsibility
• LIC 500 Personnel Report
• LIC 610D Emergency Disaster Plan

No deficiencies cited during today's inspection.

Report is reviewed with Administrator Jayson Hernandez.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Jaime Vado
LICENSING EVALUATOR SIGNATURE: DATE: 10/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/20/2022
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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