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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601061
Report Date: 09/28/2021
Date Signed: 09/28/2021 03:16:40 PM

Document Has Been Signed on 09/28/2021 03:16 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:GARDEN COURT AT THE VILLAGEFACILITY NUMBER:
415601061
ADMINISTRATOR:ALEXANDER, CARIDADFACILITY TYPE:
740
ADDRESS:137 POINSETTIA AVETELEPHONE:
(650) 269-3974
CITY:SAN MATEOSTATE: CAZIP CODE:
94403
CAPACITY: 6CENSUS: 5DATE:
09/28/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Rolito CawalingTIME COMPLETED:
03:30 PM
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On 09/28/2021, Licensing Program Analyst (LPA) Jaime Vado toured facility's building and grounds to conduct an annual infection control inspection visit. LPA met with co-administrator Rolito Cawaling and explained purpose of today's visit. At 1500hrs LPA met with licensee/administrator Caridad Alexander.

There is 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. Medications, toxins and sharps are stored appropriately and inaccessible to clients. Facility ambient temperature is comfortable 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. First-aid kit is inspected and complete. Disaster and Mass Casualty Plan is observed dated March 2021. There is 4 residents present in the facility today. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed as current. LPA observed entry questions and procedures as well as masking requirements. All are in place. Signs are present regarding masking, distancing. Disaster drill log is current with last drill conducted on 07/07/2021. LPA reviewed mitigation plan with co-administrator and she will send LIC808 to reflect any changes and LPA approval. LPA advised facility to add more masking signs as resident reminders. Administrator certificate is current expiring on 08/28/2022.

The following updated forms are requested to be submitted to CCLD by 10/05/2021:

• Administrator Certificate
• LIC 308 Designation of Administrative Responsibility
• LIC 500 Personnel Report
• LIC 610E Emergency Disaster Plan
• LIC808 Mitigation Plan

Report reviewed with licensee/administrator. No citations issued.
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Jaime Vado
LICENSING EVALUATOR SIGNATURE: DATE: 09/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/28/2021
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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