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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385600167
Report Date: 03/13/2020
Date Signed: 03/13/2020 04:31:16 PM

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:9TH AVENUE COMMUNITY CARE HOMEFACILITY NUMBER:
385600167
ADMINISTRATOR:DIMAYUGA, A & VALENCIANO,FACILITY TYPE:
740
ADDRESS:1730 - 9TH AVENUETELEPHONE:
(415) 759-5825
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94122
CAPACITY:6CENSUS: 6DATE:
03/13/2020
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:41 PM
MET WITH:Nancy Supetran and Renelee SoTIME COMPLETED:
04:40 PM
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On March 13, 2020 Licensing Program Analyst (LPA) Chris Hopkins conducted an unannounced Annual Required Inspection and met with staff Nancy Supetran. LPA stated the purpose of the inspection and was granted entry into the facility. Administrator Renelee So met LPA about 20 minutes later. One (1) residents and One (1) staff were present during the initial inspection. The facility is a 4 bedroom 2 bathroom house.

At 3:00pm LPA toured the inside premises of the facility with Nancy Supetran. Indoor passageways were free of obstruction. Hot water was tested in the main bathroom and measured at 105 degrees Fahrenheit. Resident’s bathroom was equipped with grab bars and non-slip mat for toilet, bathtub, and shower. Disinfectants, cleaning solutions and poisons are locked in the kitchen cabinet underneath the sink and inaccessible to clients. LPA observed lighting in all bedrooms. First aid kit was complete. Smoke detectors and Carbon Monoxide were present throughout the facility. Fire extinguisher was last serviced May 22, 2019. At 3:30pm Renelee took over the inspection and toured the outside premises, which was free of obstruction and no bodies of water observed. Renelee stated there are no firearms or ammunition at the facility. LPA observed nonperishable foods for a minimum of (1) one week and fresh perishable foods for a minimum of (2) two days. Centrally stored medication was locked in a kitchen cabinet and inaccessible to residents.

Staff records were reviewed. Staff on duty have current First Aid/CPR certifications on file. All staff reviewed have a fingerprint clearance on file. Client’s records were reviewed.

No deficiencies observed today.

This report was discussed with Renelee So and a copy was given to her.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Christopher Hopkins-ClarkeTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 03/13/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2020
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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