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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600805
Report Date: 11/17/2022
Date Signed: 11/17/2022 12:48:24 PM

Document Has Been Signed on 11/17/2022 12:48 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:HEIRLOOM GARDENS OF DALY CITYFACILITY NUMBER:
415600805
ADMINISTRATOR:DE LA TORRE, JOCELYNFACILITY TYPE:
740
ADDRESS:75 SURREY COURTTELEPHONE:
(650) 922-1039
CITY:DALY CITYSTATE: CAZIP CODE:
94015
CAPACITY: 6CENSUS: 6DATE:
11/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:29 AM
MET WITH:Marciano Meneses TIME COMPLETED:
12:59 PM
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On November 17, 2022, Licensing Program Analyst (LPA) Walters arrived unannounced to conduct an annual required 1-year inspection. This visit will focus primarily on the infection control practices of this facility. Upon arriving at the facility LPA was greeted by Staff, Marciano Meneses who granted LPA entrance into the facility. Administrator/ Licensee Jocelyn De La Torre was available by phone.

This facility is a two-story home with 5 bedrooms on the first floor that are approved by the fire department for non-ambulatory/ambulatory residents. There are 3 bedrooms upstairs, 2 of the 3 bedrooms are for staff. 1 of the 3 bedrooms, is for an ambulatory resident. In review of the facility sketch, LPA did not observed the second floor of the facility, therefore LPA was unable to verify that the second floor of the facility was approved for residents. Administrator to either send a copy of original sketch that has been approved by the fire department or submit a new sketch that includes: both floors, the number of occupant per a room, and their ambulatory status.

LPA continued tour of the facility with staff, Belen Ranjo. At the entrance of the facility there is a sign in sheet with hand sanitizer for visitors. LPA observed signage that promoted proper hand washing and droplet precaution. The home was a comfortable temperature, clean and was observed to be in good repair. Per staff the facility is disinfected upon usage. Bathrooms were stocked with hand washing supplies and paper products. There is at least a 30 day supply of cleaning, incontinence products, and personal protective equipment.

All bedrooms were furnished as required per regulation. Fire extinguishers were charged, last serviced on 11/03/2022. All exits and walkways were found to be unobstructed and were free of debris. Smoke and carbon monoxide detectors were tested and found to be operational.
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SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Katrina Walters
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: HEIRLOOM GARDENS OF DALY CITY
FACILITY NUMBER: 415600805
VISIT DATE: 11/17/2022
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LPA reviewed 3 of 3 staff records which included their vaccine cards. LPA advised that the Administrator/ Licensee stores the staff vaccine records in their file. LPA requested to view staff infection control training records, however staff were unable to locate any training records for infection control.
LPA is requesting that the following items by 11/30/22:
  • Copy of facility sketch.
  • Updated LIC 500
  • Copy of updated Administrator Certificate
  • Resident Roster
  • infection control training
No deficiencies cited during visit.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Katrina Walters
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)
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