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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600595
Report Date: 11/17/2022
Date Signed: 11/17/2022 03:38:06 PM

Document Has Been Signed on 11/17/2022 03:38 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
Lookup Error,
, CA
FACILITY NAME:ALHAMBRA HOME CAREFACILITY NUMBER:
415600595
ADMINISTRATOR:DEGUZMAN, HELENFACILITY TYPE:
740
ADDRESS:498 ALHAMBRA ROADTELEPHONE:
(650) 589-1900
CITY:SOUTH SAN FRANCISCOSTATE: CAZIP CODE:
94080
CAPACITY: 6CENSUS: 5DATE:
11/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:Caregiver, Judith HaliliTIME COMPLETED:
03:47 PM
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Licensing Program Analyst (LPA) Victoria Bertozzi arrived unannounced to conduct an Annual Required inspection and met with Caregiver, Judith Halili. Administrator, Rick Miranda was available by phone. The inspection is focused on the Infection Control procedures and practices of this facility.

Administrator and LPA discussed whether the Change of Administrator paperwork has been submitted to the Department and Administrator stated that it had been. LPA will provide a list of needed documents to Administrator to make the changes and Administrator agreed to send documents to LPA.

LPA initiated a walk-through of the facility around 2:20pm and observed the following: Facility has COVID-19 posters throughout that included hand washing signs in bathrooms. Facility was a comfortable temperature. Hand sanitizer is located throughout common areas of the facility. Observed staff had a mask on during this visit. Per staff, frequently touched surfaces are disinfected a couple times per week. LPA instructed staff that frequently touched surfaces must be disinfected at least once per day. Facility maintains documentation of staff and resident daily temperatures. LPA was not screened upon entry but did confirm that facility has a thermometer and a sign in log for visitors. LPA reviewed the visitor log.

During inspection LPA observed that a bed in a shared resident bedroom is partially blocking the sliding door that is identified as an exit. LPA suggested swapping the two beds as one is longer than the other. All bedrooms are approved for non-ambulatory residents per the fire clearance but a walker or wheelchair would not be able to exit out the sliding door, per LPA observation. LPA measured opening as approximately sixteen inches. LPA will reach out to the San Bruno Licensing Office to address further steps.

Continued on LIC809C
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Bertozzi
LICENSING EVALUATOR SIGNATURE: DATE: 11/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/17/2022
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 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA
FACILITY NAME: ALHAMBRA HOME CARE
FACILITY NUMBER: 415600595
VISIT DATE: 11/17/2022
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Continued from LIC809

Facility is allowing for visitation in resident rooms per CCL guidance. Staff continue to receive training on infection control and donning and doffing of Personal Protective Equipment (PPE) but have not been N95 fit tested.



Facility has at least a 30 day supply of PPE including but not limited to masks, gowns, and hand sanitizer. Facility maintains a 30 day supply of medication. Fire extinguishers were last serviced November 2022. Smoke and carbon monoxide detectors throughout facility were tested and operational.

Staff and LPA discussed their Infection Control Plan.

Licensee/Administrator to submit updates of the following documents to the San Bruno Licensing Office by 12/16/2022:
  • LIC 610 Emergency Disaster Plan (review and update)
  • Copy of Liability Insurance


Items needed for Change of Administrator
  • LIC 308 Designation of Facility Responsibility *Signed by Licensee designating Administrator
  • LIC 500 Personnel Report
  • LIC 501 Personnel Record or Administrator’s Resume
  • Administrator Certificate
  • Corporation or LLC - Minutes of meeting appointing new administrator or a Board Resolution appointing the new administrator


No deficiencies cited during this inspection.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Bertozzi
LICENSING EVALUATOR SIGNATURE:

DATE: 11/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2