Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 380500183
Report Date: 03/06/2020
Date Signed: 03/06/2020 12:02:59 PM

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:EDGEWOOD - THE SAN FRANCISCO PROTESTANT ORPHANAGEFACILITY NUMBER:
380500183
ADMINISTRATOR:ARBALLO JR., AUGUSTINEFACILITY TYPE:
733
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:48CENSUS: DATE:
03/06/2020
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Lynn Dolce-CEOTIME COMPLETED:
12:00 PM
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On March 6, 2020 Licensing Program Analyst (LPA) Isabel Mendoza, Licensing Program Manager (LPM) Zaid Hakim, and Regional Manager (RM) Nelson Martinez hosted an Informal Office Meeting at the Community Care Licensing, San Bruno Local Office, 851 Traeger Ave Suite 360, San Bruno, CA. Community Care Licensing (CCL) met with the following parties: Lynn Dolce, CEO, Christine Garcia SF county, Augie Arballo, Administrator for Edgewood, Anil Awasti, SR. Director of HR, Jessica Espinosa, Training Coordinator for Edgewood, Kimiko Burton, City Attorney, Joan Miller, Family Children Services, Deputy Director, Farahnaz Farahmand, DPH-BHS-CYS, and Troy Williams.

The purpose of the meeting is to review areas of compliance outlined in the Non-Compliance Conference (NCC) held on 10/07/19 (please refer to LIC 91111, page 3 dated 10/07/19 for further details) and to report the facilities progress.
Per the NCC the facility had 11 items/areas that the licensee agreed to follow in order to bring the facility into compliance. At this time, the facility still has not met CCL’s expectations regarding policies, procedures, and documentation for all items. During this meeting, CCL took the time to clarify CCL’s compliance expectations and provided the facility an opportunity to clarify how compliance expectations are being met.

The following was discussed:
· The facility is to create an updated Camera Waiver Addendum and will ensure to include a statement on what the cameras features, setting, operations, and accessibility. In addition, will include a sample of the camera’s positions and directions. This is due no later than 03/13/20.
· The facility will submit sign-in sheet for all staff that completed the Mandated Reporter Training back in 11/15/19. During meeting LPA obtained copy of report.
SUPERVISOR'S NAME: Zaid HakimTELEPHONE: (707) 320-3944
LICENSING EVALUATOR NAME: Isabel MendozaTELEPHONE: (408) 406-2326
LICENSING EVALUATOR SIGNATURE:

DATE: 03/06/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2020
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
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: EDGEWOOD - THE SAN FRANCISCO PROTESTANT ORPHANAGE
FACILITY NUMBER: 380500183
VISIT DATE: 03/06/2020
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· The facility is having all staff complete training on “What Grooming Looks Like” on a quarterly basis.
· As of Friday, 03/06/19 the facility has all Upper Managers recording their hours worked.
· The facility requested to do Up night upper managers check twice a month.
· The facility will review their current STRTP Program Statement and submit any changes to LPA no later than June 1, 2020.
· San Francisco Department of Public Health requested the facility to ensure to communicate to (SFDPH) when the facility is in compliance.
· The facility will develop an Upper Management checklist and will submit to LPA no later than March 20, 2020. This checklist will be used during staffs random up night visits.
The facility has agreed starting May 1, 2020 the facility will submit the following documents to LPA Mendoza on a quarterly basis. In addition, all these items must be submitted to LPA Mendoza every 1st of the month, quarterly basis.
· Personal Rights Training- All staff trained on CCL Personal Rights. The facility is to have a sign-in sheet, training materials, trainer’s information, length of training, and submit this quarterly in a full packet.
· Staff and Youth receiving training on “What Grooming Looks Like”. All staff and clients must have a sign-in sheet. Sign-in sheets for clients will include the youths full name, DOB, authorized representatives full name, and date of placement. Training for both staff and youth will include training materials and trainer’s qualification along with summary.
· Twice a month upper management will conduct unannounced up night visits and submit log, with date time, summary. This will be submitted quarterly.
· Submit complete Up night Bed Check logs- on a quarterly basis.

During the meeting, facility staff provided CCL with the following training documents: Mandated Reporting, Internal Reporting, Grooming, and Boundaries.
During the meeting, the licensee was advised that the Department takes these types of issues very seriously. The licensee was also cautioned that if there are continued deficiencies cited for similar issues, the license will be referred to our Legal Department for possible administrative action, which could include revocation.
SUPERVISOR'S NAME: Zaid HakimTELEPHONE: (707) 320-3944
LICENSING EVALUATOR NAME: Isabel MendozaTELEPHONE: (408) 406-2326
LICENSING EVALUATOR SIGNATURE:

DATE: 03/06/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2020
LIC809 (FAS) - (06/04)
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