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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600135
Report Date: 07/05/2022
Date Signed: 07/05/2022 03:23:31 PM

Document Has Been Signed on 07/05/2022 03:23 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 CARLOS ELMSFACILITY NUMBER:
415600135
ADMINISTRATOR:EVANS, SCOTTFACILITY TYPE:
740
ADDRESS:707 ELM STREETTELEPHONE:
(650) 595-1500
CITY:SAN CARLOSSTATE: CAZIP CODE:
94070
CAPACITY: 130CENSUS: 115DATE:
07/05/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Activities Director, Kathleen SullivanTIME COMPLETED:
03:35 PM
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On July 5, 2022, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced annual infection control inspection. Upon arrival LPA observed the COVID-19 signage posted on the front door. LPA met with Activities Director, Kathleen Sullivan and explained the purpose of the visit. Activities Director was able to provide LPA screening log documentation for visitors, residents and staff.

LPA toured facility and grounds. No accessible bodies of water or fire safety hazards observed. This is a 3 story building with rooms on each floor. LPA observed the laundry room on the first floor in good working condition. Due to the COVID-19 outbreak at the facility, the facility closed their dining room and is delivering meals to resident's rooms, however the tables was observed to be spread out. LPA observed the locked medication room and the 30-day PPE supply on the first floor.

All communal bathrooms were observed to be equipped with liquid soap, paper towels, hand washing signage and a trash can with a lid. LPA observed the rooms with residents under COVID isolation to have COVID-19 postings regarding isolation, COVID precautions, and PPE donning and doffing. In addition, COVID-19 isolation rooms were equipped with a covered trash can outside the rooms. Infection control practices are reviewed: entry procedures, staff training and policies, resident/ visitors/ and staff daily monitoring records, and 30-day PPE supply

LPA observed COVID-19 signage posted throughout the facility and in the facility elevator. Extra linen was observed to be present on each floor. Memory Care unit was observed to be on the 2nd and 3rd floor.

CONT. to 809C
SUPERVISORS NAME: Julio Montes
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE: DATE: 07/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/05/2022
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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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 CARLOS ELMS
FACILITY NUMBER: 415600135
VISIT DATE: 07/05/2022
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Toxins and sharps are stored appropriately and inaccessible to residents, and a comfortable temperature is maintained. Lighting is sufficient for comfort. First aid kit was observed to be completed.

LPA requests the following documents to be submitted to CCLD by July 12, 2022:
  • LIC309 Administrative Organization
  • LIC308 Designation of Administrative Responsibility
  • LIC500 Personnel Report
  • LIC400 Resident Cash Resources
  • LIC402 Surety Bond
  • Administrator Certificate
  • LIC610E Emergency Disaster Plan


Report is reviewed with Kathleen Sullivan and a copy is provided. No citations issued during this visit.
SUPERVISORS NAME: Julio Montes
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE:

DATE: 07/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2022
LIC809 (FAS) - (06/04)
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