Facility Evaluation Report

Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to conduct a Required - 1 Year visit on 9/23/23 at 9:15AM. The Administrator Certificate was observed for Annette Peig which expired 10/9/23. However, the certificate renewal documents and payment has been submitted to Community Care Licensing (CCL) and the Administrator Certificate Section (ACS) Applications Pending List was observed by LPA during this visit. The facility phone number has been changed to 650-993-8142.

LPA met with Annette Peig Administrator and stated the purpose of the visit. LPA observed a printout of the active Administrator Certificate Holders which included Aldo Montiel which expires 6/18/2024. However, Administrator has not received the certificate yet. The facility is licensed for a capacity of 4 non-ambulatory residents of which 4 maybe bedridden.

Infection Control Plan observed and submitted to Community Care Licensing (CCL).

LPA observed 3 residents participating in individual activities and 1 resident out in community during this visit. LPA observed and conversed with 1 resident during this visit.

LPA toured and inspected the physical plant inside and outside to ensure there are no safety hazards to residents.

LPA observed a posted updated Liability insurance policy.

The most recent emergency drill was 5/2/23.