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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385600340
Report Date: 02/13/2024
Date Signed: 02/13/2024 11:09:41 AM


Document Has Been Signed on 02/13/2024 11:09 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:RJ STARLIGHT HOME CORPORATIONFACILITY NUMBER:
385600340
ADMINISTRATOR:TERESITA JOMOKFACILITY TYPE:
740
ADDRESS:2680 BRYANT STREETTELEPHONE:
(415) 648-2280
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94110
CAPACITY:12CENSUS: 12DATE:
02/13/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:14 AM
MET WITH:Amelia Arcinas, CaregiverTIME COMPLETED:
11:30 AM
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On February 13, 2024, Licensing Program Analyst(LPA) John Calandra arrived at the facility at 9:14 AM to conduct an unannounced Annual 1-year required inspection. LPA Calandra met with Amelia Arcinas, Caregiver. The Administrator, Teresita Jomok was unable to join the visit.

LPA Calandra toured the physical plant. This is a story building that consists of 6 rooms and 3 bathrooms. Water in all bathrooms was measured above the 125 degrees Fahrenheit. Facility staff turned down the temperature of the water down in the presence of the LPA. Bathrooms were observed to have the required grab bars and anti-skid mats. Fire extinguishers in the facility were observed to be fully charged and last checked on April 12, 2023. The facility had the required 7 days of non-perishables and 2 days of perishables on site. No food was expired. The kitchen refrigerators and freezers temperature was within the required range. All bedrooms were sufficiently lit and had the required furniture. The backyard was clear from obstructions. No accessible bodies of water or hazards were observed. The facility's first aid was observed to be complete. The facility does not handle any cash resources. The facility was maintained at a comfortable temperature of 70 degrees Fahrenheit.

All knives and sharp objects were observed to be locked and in-accessible to persons in care. All medications, soaps, and detergents were observed to be locked and in-accessible to persons in care.

A review of Centrally stored medications indicated that medications for residents were properly labeled with instructions on dosage and times of day and matched the Centrally Stored Medication records kept at the facility.

LPA Calandra reviewed 5 resident and 3 staff files. All were observed to be complete.

No deficiencies were cited during today's visit. The report was reviewed with Caregiver, Amelia Arcinas and a copy was left at the facility.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: John CalandraTELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 02/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/13/2024
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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