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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 419210099
Report Date: 09/23/2023
Date Signed: 09/23/2023 05:08:16 PM

Document Has Been Signed on 09/23/2023 05:08 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
SAN BRUNO RO, 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:
09/23/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Amy LeeTIME COMPLETED:
05:15 PM
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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to conduct a Required - 1 Year visit on 9/23/23 at 2:00PM. The facility is licensed for 4 residents of which 4 maybe bedridden. Hospice waiver approved for 1. LPA met with Amy Lee, Administrator and Claire Ascalon, RN Consultant and stated the purpose of the visit.

LPA observed the P&I monies for R1 that was counted and documented appropriately and not commingled during this visit. There are 0 residents receiving hospice care services during this visit.

Infection Control Plan observed and submitted to Community Care Licensing (CCL).

LPA observed 4 residents participating in individual activities during this visit.

LPA toured and inspected the physical plant inside and outside to ensure there are no safety hazards to residents. LPA observed a posted updated Liability insurance policy.

The most recent emergency drill was July 12, 2023. LPA observed 2-day perishables and 7-day non-perishables.

The temperature inside the facility was observed to be at 77*F which is within the required range of 68-85*F. The hot water temperature was measured at 111.0*F which is within the required range of 105-120*F.

LPA observed fire extinguisher(s), smoke and carbon monoxide detectors, and central heating and air in the facility. LPA observed the facility has a pull alarm system. LPA observed the centrally stored medications area to be locked and inaccessible to residents.
SUPERVISORS NAME: Victoria Brown
LICENSING EVALUATOR NAME: Victoria Brown
LICENSING EVALUATOR SIGNATURE: DATE: 09/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/23/2023
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: LOUVAINE HOME
FACILITY NUMBER: 419210099
VISIT DATE: 09/23/2023
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The first aid kit contained the required items such as sterile dressings, bandages, adhesive tape, scissors, tweezers, thermometers, antiseptic solution and guide.

LPA observed 2 staff files and 2 resident files during this visit. LPA conducted interviews of staff during this visit.

Upon a file review the following items were discussed to be submitted with any changes annually:
Any addendums to Infection Control Plan, Designation of Facility Responsibility (LIC308), Liability Insurance
Personnel Report (LIC500) to include the Administrator presence in the facility, Administrator Certificate-Updated, Affidavit regarding client/resident Cash Resources (LIC400), Control of Property, Surety Bond (LIC402), any updates to Administrative Organization (LIC309).


Per the California Code of Regulations, Title 22, Division 6, Chapter 6, no deficiencies observed or cited. Exit interview held, copy of report given
SUPERVISORS NAME: Victoria Brown
LICENSING EVALUATOR NAME: Victoria Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 09/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2023
LIC809 (FAS) - (06/04)
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