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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385600277
Report Date: 11/26/2024
Date Signed: 11/26/2024 11:46:25 AM

Document Has Been Signed on 11/26/2024 11:46 AM - 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:SFAL - THE AVENUEFACILITY NUMBER:
385600277
ADMINISTRATOR/
DIRECTOR:
WONG, TERESAFACILITY TYPE:
740
ADDRESS:1035 VAN NESS AVENUETELEPHONE:
(415) 776-1800
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94109
CAPACITY: 145CENSUS: 14DATE:
11/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:40 AM
MET WITH:Mindy Han, Administrator TIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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On 11/26/2024, Licensing Program Analyst (LPA) Tobola conducted an unannounced Annual Required – 1 yr. inspection for this facility and was greeted by Administrators, Mindy Han & Teresa Wong. The facility currently provides care for 14 residents, 1 of which is receiving hospice services and some of which with a diagnosis of dementia. There are 2 residents residing in the Assisted Living portion of the facility with the remaining 12 residents residing in memory care.

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 on each resident floor, kitchen and common spaces were found to be charged. Facility is equipped with smoke and carbon monoxide detectors and fire safety systems monitored and serviced by outside agencies.

There was a sufficient supply of both perishable and nonperishable foods as required, with food stored in the kitchen, sufficient for residents in care. Food supply is replenished constantly throughout the week and stored properly. Facility provides a wide variety of meal preferences and preparation while also ensuring proper dietary restrictions are followed. Cleaning supplies and other toxins are safely stored in locked closets throughout each floor, all of which were secured upon inspection. There was a supply of hygiene products and paper products available for residents. All resident’s bedrooms have lighting & appropriate furnishings and bedding items.

Residents that were out in the community during the inspection were observed interacting with staff, fellow residents in the common areas, participating in activities and exercise. The facility encourages regular family visits and utilizes two outdoor patio spaces a multipurpose room and several visitation areas for resident use. Continued onto LIC809-C
SUPERVISORS NAME: Andrea Medlin
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE: DATE: 11/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/26/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: SFAL - THE AVENUE
FACILITY NUMBER: 385600277
VISIT DATE: 11/26/2024
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LPA conducted a sample file review for residents and found all items to be in order including needs & service plans and physician's reports. Upon a spot check of staff files, LPA found that caregiver staff have current 1st aid and CPR and annual training completed. Lastly, A spot check of medications including narcotic was conducted and found that all medication counts and records to be in order.

Mindy Han's Administrator Certificate is currently active through 8/3/2025
Teresa Wong's Administrator Re-certification has been received and pending

LPA requested the following documents be sent to CCL by COB 12/10/2024:

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

No deficiencies cited during today's visit.
SUPERVISORS NAME: Andrea Medlin
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:

DATE: 11/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/26/2024
LIC809 (FAS) - (06/04)
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