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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803663
Report Date: 06/25/2021
Date Signed: 06/25/2021 10:47:17 AM

Document Has Been Signed on 06/25/2021 10:47 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
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:GARDEN HOMEFACILITY NUMBER:
216803663
ADMINISTRATOR:ZHU, XIAOTONG "SHERRY"FACILITY TYPE:
740
ADDRESS:16 GARDEN AVETELEPHONE:
(415) 350-6636
CITY:SAN RAFAELSTATE: CAZIP CODE:
94903
CAPACITY: 4CENSUS: 4DATE:
06/25/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Administrator, Sherry ZhuTIME COMPLETED:
11:10 AM
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Licensing Program Analysts (LPA) Farhaan Sarangi and Erik Gonzalez Campos arrived unannounced, to conduct a Required-1 year inspection and were greeted by administrator Sherry Zhu. Administrator granted access into the facility. The inspection is focused on the Infection Control procedures and practices of this facility.

Upon arrival, LPAs were screened by administrator and screening was documented. LPAs initiated walk-through of the facility with the Administrator at 10:15 AM and observed COVID-19 posters throughout the facility that included hand washing signs. Facility staff assist clients with hand washing. Facility was a comfortable temperature and exits were free from obstructions. Infection control has been discussed with clients and staff. Hand sanitizer is located centrally for client and staff use. Observed staff had masks on during this visit. Commonly touched surfaces are disinfected on each shift.

Clients are staggered and socially distanced during meals. Common areas are set up for social distancing. Facility has a designated visitation area. Staff have completed PPE training.

LPAs provided guidance to submit revised mitigation plan by July 1, 2021.

Facility has over 70 percent vaccination rate of staff and clients and has therefore discontinued surveillance testing.

LPAs confirmed administrator reviewed the following: PINs 21-17-ASC and 21-17.1-ASC for new guidance regarding visitation, communal dining, surveillance testing, etc.



Administrator and LPA discussed their Emergency Disaster Plan. No deficiencies cited during this inspection. Exit interview was conducted and a copy of this report was emailed to the Administrator, Sherry Zhu.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Erik Gonzalez Campos
LICENSING EVALUATOR SIGNATURE: DATE: 06/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/25/2021
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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