<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385600421
Report Date: 11/09/2022
Date Signed: 11/15/2022 05:54:39 PM

Document Has Been Signed on 11/15/2022 05:54 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
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:CAYCO'S CARE HOMEFACILITY NUMBER:
385600421
ADMINISTRATOR:CAYCO, MARIBEL GFACILITY TYPE:
740
ADDRESS:1855 35TH AVENUETELEPHONE:
(415) 665-9409
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94122
CAPACITY: 6CENSUS: 5DATE:
11/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Caregiver, Jude Frederick TorresTIME COMPLETED:
11:05 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 11/9/22, Licensing Program Analyst(LPA) Murial Han conducted an unannounced annual inspection. LPA observed COVID-19 signs posted by the entrance. LPA was greeted by staff, Jude Frederick Torres. LPA explained the purpose of the visit and LPA was 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.

During the inspection, LPA observed 2 male residents in the living room on the 1st floor and 2 female residents downstairs. there are 2 private rooms and 1 semi-private room on the 1st floor with beds observed to be 6" apart. PPE supply and the environmental cleaning supply are adequate and appropriately stored, bathrooms are equipped with liquid soap and paper towels, hand washing instruction is posted by the hand washing stations. Trash cans are observed to have foot operated lids.

Medications, toxins and sharps are stored appropriately and inaccessible to resident, a comfortable temperature is maintained, lighting is sufficient for comfort and safety and food supply was checked and observed to be sufficient. First-aid kit is inspected and complete.

In regards to residents and staff screening, staff reported that everyone is being tested for COVID-19 on a daily basis instead of the daily screening process. LPA reminded staff that residents, and fully vaccinated staff members are not required to have daily testing as well as visitors. LPA shared PIN 22-28- ASC with staff for additional details. Staff is instructed to resume the daily screening process.

No deficiency cited today
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE: DATE: 11/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/09/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1