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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601010
Report Date: 02/15/2023
Date Signed: 02/15/2023 03:38:53 PM

Document Has Been Signed on 02/15/2023 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
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:AJAVINIAR HOME CARE SERVICES LLCFACILITY NUMBER:
415601010
ADMINISTRATOR:CRUZ DIAZ, ROWENAFACILITY TYPE:
740
ADDRESS:1024 NORTON STTELEPHONE:
(650) 477-2363
CITY:SAN MATEOSTATE: CAZIP CODE:
94401
CAPACITY: 6CENSUS: 5DATE:
02/15/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Leo SisonTIME COMPLETED:
03:30 PM
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 this day, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced infection control annual inspection. LPA met with administrator Leo Sison and explained purpose of today's inspection.

Upon entry there were no COVID signs on the exterior of the front door of the facility. According to staff, they were instructed to remove by the local long term care ombudsman. LPA advised on re-posting those signs. There are 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 observed as in place stored in rear shed. Medications, toxins and sharps are stored appropriately and inaccessible to clients. Facility ambient temperature is warm and comfortable, and lighting is sufficient for residents and staff safety. Toilet and bathing facilities are equipped with grab bars and non-skid flooring material. Liquid soap is available for each resident in their room and is brought to the restroom when they use the restroom. First-aid kit are inspected and is complete. A Disaster and Mass Casualty Plan is observed. Staff is observed wearing masks. Food supplies are observed as in place. Two day perishable and one week non-perishable food supplies are observed as in place. Water temperature is taken in common resident bathroom reading 112F. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed. Mitigation and infection control plans are current and reviewed with staff.

The following updated forms are requested to be submitted to CCLD by 02/22/2023:

• Updated Administrator Certificate
• Updated surety bond with expiration date
• LIC 308 Designation of Administrative Responsibility
• LIC 309 Administrative Organization
• LIC400 Affidavit Regarding Client/Resident Cash Resources
• LIC402 Surety Bond
• LIC 500 Personnel Report
• LIC 610E Emergency Disaster Plan

No citations issued. Report is reviewed with Leo.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Jaime Vado
LICENSING EVALUATOR SIGNATURE: DATE: 02/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/15/2023
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