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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385600382
Report Date: 01/26/2024
Date Signed: 01/26/2024 05:51:02 PM


Document Has Been Signed on 01/26/2024 05:51 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:CARE AND CARE RESIDENCE IIFACILITY NUMBER:
385600382
ADMINISTRATOR:NEVAREZ, JOSEFACILITY TYPE:
740
ADDRESS:901 GRAFTON AVENUETELEPHONE:
(415) 715-8400
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94112
CAPACITY:6CENSUS: 4DATE:
01/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:23 PM
MET WITH:Lucila PanganibanTIME COMPLETED:
05:30 PM
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On 1/26/24, LPA Grace Donato made an unannounced annual visit to the facility. LPA met with Caregiver Lucila Panganiban. LPA explained the purpose of the visit.

LPA toured the facility inside and outside including all of resident rooms, garage/storage area, and kitchen area. Residents are currently resting in their rooms resting and others are watching. It was observed that the room temperature was 68 deg F. Hot water was also tested in the bathrooms and the temperature was 108 deg F. The facility is observed to be clean, odorless, and well maintained. Residents’ bedrooms were observed to be organized and fully furnished with adequate lighting. Sharps and toxic materials were observed to be locked. Food supply was observed with an adequate two-day perishable and seven-day non-perishable food supply. Carbon monoxide/smoke detectors, and fire extinguisher were present throughout the facility. The facility has an updated log for emergency drill which is done every quarter.

Four resident records and four staff records were reviewed. Staff have criminal record and fingerprint clearances on file. Staff have current First Aid/CPR certifications on file. Resident records were reviewed and were observed to be complete. All medication logs are complete and updated.

LPA requested the following documents: LIC 308, Certificate of Liability Insurance, LIC 500, Control of Property.

No deficiencies are cited at this time. Report is reviewed and a copy is provided.
SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8865
LICENSING EVALUATOR NAME: Grace DonatoTELEPHONE: (714) 293-8294
LICENSING EVALUATOR SIGNATURE:
DATE: 01/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/26/2024
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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