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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 380540323
Report Date: 11/08/2024
Date Signed: 11/08/2024 04:25:04 PM

Document Has Been Signed on 11/08/2024 04:25 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:DAVID ARDOIN 2FACILITY NUMBER:
380540323
ADMINISTRATOR/
DIRECTOR:
ARDOIN, DAVIDFACILITY TYPE:
735
ADDRESS:1582 VAN DYKE AVENUETELEPHONE:
(415) 685-9316
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94124
CAPACITY: 6CENSUS: 1DATE:
11/08/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:15 PM
MET WITH:Raymond BarajasTIME VISIT/
INSPECTION COMPLETED:
04:45 PM
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On 11/08/2024, Licensing Program Analyst (LPA) Yi Sam Jian conducted an unannounced annual inspection. LPA met with staff member, Ramon Barajas and Administrator, David Ardoin, joined later of the day. LPA explained the purpose of the visit.

Renovations to the garage, laundry room and bathroom is observed in the lower level. There is also construction taking place in the upper level consisted of living room, dining room, kitchen, 1 bathroom, and 1 bedroom for client.

Backyard was fenced, secured, and in good condition. All outdoor and indoor passageway were free and clear of obstruction. No accessible bodies of water or fire safety hazards observed.

Kitchen was inspected, sufficient supply of food observed. Infection control practices reviewed. Medications, toxins and sharps stored appropriately and inaccessible to clients, a comfortable temperature was maintained, hot water temperature inspected to be compliant, furnishing and lighting was sufficient for comfort and safety.

Carbon monoxide detector and smoke detector system inspected and met the requirements. fire extinguisher checked and fully charged. Facility has a written emergency disaster plan. Licensee has at least one completed first aid kit located in the kitchen.

Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed.

No Deficiencies cited. This report is reviewed and discussed with the Administrator; a copy is provided.
SUPERVISORS NAME: Andrea Medlin
LICENSING EVALUATOR NAME: Yi Sam Jian
LICENSING EVALUATOR SIGNATURE: DATE: 11/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/08/2024
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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