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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385600167
Report Date: 02/05/2025
Date Signed: 02/05/2025 02:37:42 PM

Document Has Been Signed on 02/05/2025 02:37 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:9TH AVENUE COMMUNITY CARE HOMEFACILITY NUMBER:
385600167
ADMINISTRATOR/
DIRECTOR:
DIMAYUGA, A & VALENCIANO,FACILITY TYPE:
740
ADDRESS:1730 - 9TH AVENUETELEPHONE:
(415) 759-5825
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94122
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 6DATE:
02/05/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:17 PM
MET WITH:Ren So, Admnistrator TIME VISIT/
INSPECTION COMPLETED:
02:45 PM
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On 2/5/2025, Licensing Program Analyst (LPA) Tobola conducted an unannounced Annual Required – 1 yr. inspection for this facility and was greeted by Administrator, Ren So. The facility currently provides care for 6 residents, none of which are receiving hospice services, or with a diagnosis of dementia.

LPA continued with a tour of the facility with staff, facility found to be clean and at a comfortable temperature with all exits free from obstruction. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguishers located throughout the facility were found to be charged. Smoke detectors were present in each common room and resident bedroom. Carbon monoxide detector located in hallway was tested an in working order. Emergency disaster plan is reviewed and updated on a regular basis.

There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations, with food stored in the kitchen refrigerator found to have appropriate coverings, enough for residents in care. Cleaning supplies and other toxins are safely stored upon inspection. There was a supply of hygiene products and paper products available for residents. Resident's bedroom have lighting & appropriate furnishings and bedding items. Restrooms for resident use were equipped with non-slip mats, grab bars and kept in good condition. There is a large outdoor patio equipped with appropriate shading for resident use. Medications are stored in the kitchen and found to be secured. Upon spot review of medications, LPA found that the facility has centrally store medication records updated and in order.

LPA conducted a sample file review for residents and found that residents have updated physician's reports and Individual Service Plans up to date. Upon a sample review of 3 staff files LPA found that all caregiver staff have current 1st aid and CPR certification, annual training, health screening reports on file.

LPA requested the following documents be sent to CCL by COB 2/19/2024:

LIC 308 Designated Facility Responsibility
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan

No deficiencies cited during today's visit.
Andrea MedlinTELEPHONE: (650) 266-8811
Dominic TobolaTELEPHONE: (650) 393-9128
DATE: 02/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/05/2025
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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