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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 419210071
Report Date: 10/03/2022
Date Signed: 10/03/2022 10:17:02 AM

Document Has Been Signed on 10/03/2022 10:17 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:NORCAL CARE HOMES, INC.FACILITY NUMBER:
419210071
ADMINISTRATOR:RUSSLYN OLGA A GUEVARRAFACILITY TYPE:
735
ADDRESS:460 BODEGA STREETTELEPHONE:
(650) 377-2530
CITY:FOSTER CITYSTATE: CAZIP CODE:
94404
CAPACITY: 3CENSUS: 3DATE:
10/03/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Licensee, Fatollah GlichlooTIME COMPLETED:
10:25 AM
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On October 3, 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 Licensee, Fatollah Glichloo and Administrator, Russlyn Guevarra joined shortly thereafter. LPA explained the purpose of the visit. LPA was screened at entry point and Licensee was able to provide staff, visitor, and resident screening log documentation.

LPA toured the facility and grounds. No accessible bodies of water or fire safety hazards observed. This is a single story home with 3 resident bedrooms, 2 full bathrooms, and an office room. LPA toured the facility with the Licensee and observed living room and dining room to be clean and free from any tripping hazards. A comfortable temperature is maintained and lighting is sufficient for comfort. During the visit, there were no residents present. According to the Licensee, all residents were at their day program.

LPA toured the resident rooms and observed all 3 resident rooms to be single rooms. LPA observed 2 full bathrooms to be equipped with liquid soap, paper towels, hand-washing signs, non-skid mats, and a trash can with a fitted lid. Bathrooms were odor-free and in good repair. LPA observed extra linen present. LPA toured the kitchen and observed 2 day perishable and 7 day non-perishable. Sharps and medications were observed to be locked and inaccessible to residents.

LPA toured the garage and observed chemicals and toxins to be locked. In addition, LPA observed washer and dryer to be in good working condition and observed extra food supply present. 30-day PPE supply was present. The garage is the central entry point for all visitors and staff.

Infection control practices are observed: entry procedures, daily monitoring log for staff, residents and visitors, 30-day PPE supply, face coverings for staff, containment strategies, staff training and policies.

No citations will be issued during this visit. Report is reviewed with Licensee and a copy is provided.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE: DATE: 10/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/03/2022
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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