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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385600399
Report Date: 09/29/2021
Date Signed: 09/29/2021 02:32:18 PM

Document Has Been Signed on 09/29/2021 02:32 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:SAN FRANCISCO RCFEFACILITY NUMBER:
385600399
ADMINISTRATOR:ADELA MORALESFACILITY TYPE:
740
ADDRESS:887 POTRERO AVENUETELEPHONE:
(628) 206-6436
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94110
CAPACITY: 59CENSUS: 38DATE:
09/29/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Administrator, Adela MoralesTIME COMPLETED:
01:30 PM
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On 9/29/2021, Licensing Program Analyst(LPA) Murial Han and LPA Komal Charitra conducted an unannounced annual inspection. LPAs observed COVID-19 signs posted by the entrance. LPAs were greeted by the Director of Behavioral Health Center, Linda SIms and the Administrator, Adela Morales joined shortly thereafter. LPA Han and LPA Charitra explained the purpose of the visit and LPAs were screened at the front entrance.

LPA toured facility and grounds. No accessible bodies of water or fire safety hazards observed. Infection control practices are reviewed: entry procedures, staff training and policies, resident and staff daily monitoring records, containment strategies (facility has designated 2 private rooms, 1 semi-private room, 1 shower room and 2 bathrooms for the quarantine and isolation purposes when needed), PPE supply and the environmental cleaning supply are adequate (the Director of Behavioral Health Center reviews the PPE inventory on a daily basis and replenishes the supplies when needed), bathrooms are equipped with soap and paper towels, however, there are no hand-washing signs posted; some signs are posted through-out the facility such as social distancing in different languages, cough etiquette, etc; trash cans are observed to have foot operated lids.

Medications, toxins and sharps are stored appropriately and inaccessible to resident, and a comfortable temperature is maintained, lighting is sufficient for comfort. There were signs/stickers on the floor in the elevators and thought-out the facility to remind everyone to maintain social distancing. Residents were observed to be maintaining social distancing during mealtime and in the TV room.
SUPERVISORS NAME: Julio Montes
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE: DATE: 09/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/29/2021
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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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: SAN FRANCISCO RCFE
FACILITY NUMBER: 385600399
VISIT DATE: 09/29/2021
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LPA Han requested for the following documents to be submitted by 10/4/2021 by noon:

- Proof Administrator Certification was submitted,
- LIC 500
- LIC 402
- LIC 308
- Review LIC 555

LPAs discussed the following recommendations during the inspection:

- Post additional COVID-19 signs in the hallways, the common areas/dinning rooms, the staff lounge, the bathrooms, and the shower rooms.
- Post hand-washing signs above each sink.
- Remove 2 chairs from the table in the staff lounge and mark off one of the seats on the double seated couch to ensure social distancing is maintained.


No deficiency cited today. This report is reviewed and discussed with the Administrator and the Director of Behavioral Center and a copy is provided.
SUPERVISORS NAME: Julio Montes
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2021
LIC809 (FAS) - (06/04)
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