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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 419210099
Report Date: 07/28/2022
Date Signed: 08/02/2022 04:49:29 PM

Document Has Been Signed on 08/02/2022 04:49 PM - 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:LOUVAINE HOMEFACILITY NUMBER:
419210099
ADMINISTRATOR:AMY SORONGONFACILITY TYPE:
735
ADDRESS:1732 LOUVAINE DRIVETELEPHONE:
(650) 580-3896
CITY:DALY CITYSTATE: CAZIP CODE:
94015
CAPACITY: 4CENSUS: 4DATE:
07/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Caregivers, Myla Jumaani and April LuceroTIME COMPLETED:
11:10 AM
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On 7/28/2022, Licensing Program Analyst(LPA) Murial Han conducted an unannounced annual inspection. LPA observed COVID-19 signs posted by the entrance. LPA was greeted by caregivers, April Lucero and Myla Jumaani. LPA explained the purpose of the visit and LPA was properly screened at the front entrance.

LPA toured facility and grounds. No accessible bodies of water or fire safety hazards observed. Infection control practices are reviewed: entry procedures, staff training and policies, resident and staff daily monitoring records, containment strategies, PPE supply is adequate with environmental preparation and cleaning, bathrooms are equipped with soap and paper towels, hand washing instruction is posted by the hand washing stations. Trash cans are observed to have foot operated lids. LPA observed COVID-19 signs posted through-out the facility.

Medications, toxins and sharps are stored appropriately in a lock medication cart and inaccessible to clients, a comfortable temperature is maintained, lighting is sufficient for comfort and safety and food supply was checked and observed to be sufficient. First-aid kit is inspected and complete. There are 4 residents, and 2 staff members during the inspection. All the rooms are private.

No deficiency cited today. This report is reviewed and discussed with caregiver, April Lucero. A copy is provided.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE: DATE: 07/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/28/2022
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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