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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 419210106
Report Date: 07/11/2022
Date Signed: 07/11/2022 01:58:18 PM

Document Has Been Signed on 07/11/2022 01:58 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
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:FENIX HOMEFACILITY NUMBER:
419210106
ADMINISTRATOR:LILIBETH LETRONDOFACILITY TYPE:
735
ADDRESS:437 FERNDALE AVETELEPHONE:
(650) 580-1266
CITY:SOUTH SAN FRANCISCOSTATE: CAZIP CODE:
94080
CAPACITY: 4CENSUS: 4DATE:
07/11/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Lilibeth LetrondoTIME COMPLETED:
02:00 PM
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On this day Licensing Program Analysts (LPA) Jaime Vado conducted an unannounced infection control annual inspection. LPA met with caregiver caregiver Welisa and explained purpose of today's inspection. Later during the visit the licensee Lilibeth Letrondo arrived at the facility.

LPA toured the physical plant inside and out. There are no accessible bodies of water or fire safety hazards observed. COVID postings and hand washing signs are present inside the facility but not on the main entrance due to the door being newly painted. LPA advised posting the sign back up. Hand sanitizer is observed as readily available through out the facility. 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. Medications, toxins and sharps are stored appropriately and inaccessible to clients. Facility ambient temperature is warm and comfortable, and lighting is sufficient for residents and staff safety. Toilet and bathing facilities are equipped with grab bars and bath floor is textured non-slip flooring. Liquid soap is available an paper towels are present in bathrooms. Water temperature is tested in hallway bathroom at 110F. First-aid kit is inspected and is complete. A disaster and mass casualty plan is present. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been finger print cleared and associated to the facility. Mitigation plan is reviewed with Welisa and it is current. P&I is also audited and is current. Cleaning supplies are observed as locked in the garage and upper storage cabinets in the laundry room. Laundry machine and dryer observed as functioning. Emergency food supply and PPE are also located in facility garage. Fire extinguishers are observed and charged ready for use. Last inspected on 6/8/2022. Linens for residents are stored in each room for that specific resident use. All residents and staff are fully vaccinated at this time with booster. Administrator certificate is expires July, 26 2022 but licensee provided LPA confirmation of completion of training and submittal of payment for renewal.

The following updated forms are requested to be submitted to CCLD by 07/18/2022:

• Copy of new administrator Certificate when received
• LIC 308 Designation of Administrative Responsibility
• LIC 500 Personnel Report
• LIC 400 Affidavit Regarding Client Cash Resources
• LIC 610D Emergency Disaster Plan
• LIC 9020 Register of Facility Clients

Report is reviewed with administrator/licensee Lilibeth.

No deficiencies cited today.
SUPERVISORS NAME: Julio Montes
LICENSING EVALUATOR NAME: Jaime Vado
LICENSING EVALUATOR SIGNATURE: DATE: 07/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/11/2022
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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