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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 419210080
Report Date: 08/25/2021
Date Signed: 08/26/2021 09:52:26 AM

Document Has Been Signed on 08/26/2021 09:52 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
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:GLORIA'S HOMEFACILITY NUMBER:
419210080
ADMINISTRATOR:MICHELLIN A MARIANOFACILITY TYPE:
735
ADDRESS:1666 WOLFE DRIVETELEPHONE:
(650) 638-1182
CITY:SAN MATEOSTATE: CAZIP CODE:
94402
CAPACITY: 4CENSUS: 4DATE:
08/25/2021
TYPE OF VISIT:Case Management - COVID-19ANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Mnemosyne VegaTIME COMPLETED:
10:45 AM
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On August 25, 2021, Licensing Program Analyst (LPA) Michael Garcia conducted a case management tele-visit to provide Technical Assistance (TA) to the facility regarding COVID-19 with the assistance from Helen Shi, RN, licensing program clinical consultant. The TA visit was conducted with Mnemosyne Vega, administrator.

The facility's COVID-19 mitigation protocol was discussed. A resident room and the facility’s common areas were toured including the garage/screening area, dining room, backyard, and restrooms.

The TA visit resulted with the following recommendations:
- Assign a designated staff to conduct screening of COVID-19 symptoms.
- Document vaccination status of visitors.
- Post updated poster (provided) of Symptoms of Coronavirus (COVID-19) at the screening area and at common areas of the facility.
- Provide staff training regarding how to recognize symptoms of COVID-19.
- Provide staff training regarding how to wear full Personal Protective Equipment (PPE).
- Post proper donning and doffing of PPE at the garage/screening area.

Administrator shall ensure to email a signed and dated action plan regarding the above recommendations to LPA within 24 hours.

Report reviewed and discussed with administrator at the end of the visit.

An electronic copy of the report was emailed to administrator for signature.
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Michael Garcia
LICENSING EVALUATOR SIGNATURE: DATE: 08/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/25/2021
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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