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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600993
Report Date: 06/11/2021
Date Signed: 06/15/2021 06:13:22 PM

Document Has Been Signed on 06/15/2021 06:13 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:PACIFIC CARE HOME IVFACILITY NUMBER:
415600993
ADMINISTRATOR:JISON, RAFAELFACILITY TYPE:
740
ADDRESS:92 WEST 41ST AVENUETELEPHONE:
(650) 477-2474
CITY:SAN MATEOSTATE: CAZIP CODE:
94403
CAPACITY: 6CENSUS: 6DATE:
06/11/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Myra Abrazaldo, Lito Torres, Moddie AndayaTIME COMPLETED:
06:00 PM
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LPA Audrey Jeung toured facility and grounds, consisting of 6 private client bedrooms--all with full private bathrooms--and a staff bedroom for 2 staff. No accessible bodies of water or fire safety hazards observed. Infection control practices are reviewed: entry procedures, staff training and policies, resident monitoring, containment strategies, environmental preparation and cleaning. PPE supply is adequate. Medications, toxins and sharps are stored appropriately and inaccessible to clients, a comfortable temperature is maintained, and lighting is sufficient for comfort and safety. Toilet and bathing facilities are equipped with grab bars and nonskid flooring material. Liquid soap is available at all sinks. First-aid kit is inspected and complete. An updated Disaster and Mass Casualty Plan is posted. There are 6 residents present, and 2 staff. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed. Rafael Jison is a certified RCFE administrator (x 3/22) that oversees facility operations.

The following updated forms/information are requested to be submitted to CCLD BY 6/18/21:

• LIC 308 Designation of Administrative Responsibility
• LIC 500 Personnel Report
• Proof of current Liability Insurance is given to LPA today


No deficiencies of the RCFE California Code of Regulations, Title 22, Division 6, Chapter 8 are observed. Facility is operating in substantial compliance..
SUPERVISORS NAME: Julio Montes
LICENSING EVALUATOR NAME: Audrey Jeung
LICENSING EVALUATOR SIGNATURE: DATE: 06/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/11/2021
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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