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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 419210118
Report Date: 12/22/2022
Date Signed: 12/22/2022 11:18:46 AM

Document Has Been Signed on 12/22/2022 11:18 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:INSIGHT ARF, INC.FACILITY NUMBER:
419210118
ADMINISTRATOR:CANON, LYNDONFACILITY TYPE:
735
ADDRESS:4 ODESSA COURTTELEPHONE:
(650) 362-4916
CITY:REDWOOD CITYSTATE: CAZIP CODE:
94063
CAPACITY: 4CENSUS: 4DATE:
12/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Caregiver Rommel Canon TIME COMPLETED:
11:30 AM
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On December 22, 2022, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced annual infection control inspection. LPA met with Caregiver, Rommel Canon and explained the purpose of the visit. LPA observed the COVID-19 signage posted at the front entrance and was screened at entry point. Caregiver was able to provide screening log documentation for visitors and residents, however screening log documentation was not provided for staff. LPA advised caregiver to ensure staff are screened and a log is maintained.

LPA toured the facility and grounds. No accessible bodies of water or fire safety hazards observed. During the visit LPA observed one resident and two staff members. According to the caregiver, the other three residents were at their day program. This is is a single story home with five bedrooms and two full bathrooms. LPA toured the bedrooms and observed four bedrooms to be single resident rooms, and observed one bedroom to be utilized as an office room/staff room. LPA observed two full bathrooms to be equipped with paper-towels, liquid soap, trash can with a fitted lid, and non-skid mats. Bathrooms were odor-free and in good repair.

LPA observed living room and dining room to be clean and free from any tripping hazards. A comfortable temperature of 68 degrees F is maintained and lighting is sufficient for comfort. LPA toured the laundry room and observed chemicals and toxins to be locked and inaccessible to residents. Washer and dryer were observed to be in good working condition. Extra linen was present. LPA toured the kitchen and observed 2 day perishable and 7 day non-perishable. Sharps, medications, and toxins were observed to be locked and stored appropriately and inaccessible to residents. LPA observed pantry and the extra food supply present. Kitchen sink was equipped with liquid soap and paper-towels. 30-day PPE supply was present.

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

LPA requests the following forms to be submitted to CCLD by 12/29/22:
-LIC308 Designation of Administrative Responsibility
-LIC500 Personnel Report
-LIC610D Emergency Disaster Plan
-Administrator Certificate

No citations will be issued during this visit. Report is reviewed with Caregiver and a copy is provided.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE: DATE: 12/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/22/2022
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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