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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 380504099
Report Date: 08/20/2024
Date Signed: 08/20/2024 02:55:17 PM


Document Has Been Signed on 08/20/2024 02:55 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066



FACILITY NAME:KIMOCHI HOMEFACILITY NUMBER:
380504099
ADMINISTRATOR:CHAN, LINDA ISHIIFACILITY TYPE:
740
ADDRESS:1531 SUTTER STREETTELEPHONE:
(415) 922-9972
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94109
CAPACITY:20CENSUS: 14DATE:
08/20/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:46 PM
MET WITH:Linda Chan, Director of Residential ServicesTIME COMPLETED:
03:00 PM
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On 8/20/2024, Licensing Program Analyst (LPA) Tobola arrived unannounced for the purpose of conducting a case management, following up on facility incident report. An incident occurring on 8/17/2024 involving resident (R1) leaving the facility unassisted. LPA toured the facility and interviewed Director of Residential Services, Linda Ishii. Based on interview, R1 had not previously demonstrated this behavior or desire to leave the facility site. The facility contacted appropriate parties including local police department and R1's POA and submitted an incident report to CLLD. R1 had been located at the local medical center in close proximity to the facility. R1 was assessed and found no signs of injury or changes of condition and safely returned.

Based upon a review of R1's records, it was found that R1 is cleared by their physician to leave the facility unassisted and does not have a diagnosis of dementia. LPA and Administrator discussed several items following the incident, including supervision and reassessments for R1, in order to prevent further incidents from occurring. Facility to provide LPA with copies of R1's updated records once completed.

In addition, LPA and Director of Residential Services discussed request for Fire Clearance Inspection. LPA was provided request documentation. Facility to provide updated facility sketch prior to LPA submitting inspection request to local fire department.

No deficiencies cited during today's visit.
SUPERVISOR'S NAME: Andrea MedlinTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Dominic TobolaTELEPHONE: (650) 393-9128
LICENSING EVALUATOR SIGNATURE:
DATE: 08/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/20/2024
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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