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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385600401
Report Date: 08/08/2024
Date Signed: 08/08/2024 04:46:16 PM


Document Has Been Signed on 08/08/2024 04:46 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:BYXBEE HOMEFACILITY NUMBER:
385600401
ADMINISTRATOR:MARIA JASMIN NELSONFACILITY TYPE:
740
ADDRESS:383 BYXBEE STREETTELEPHONE:
(415) 586-4663
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94132
CAPACITY:4CENSUS: 4DATE:
08/08/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Maria Jasmin Nelson, AdministratorTIME COMPLETED:
05:00 PM
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On 8/8/2024, Licensing Program Analyst (LPA) Tobola conducted an unannounced Annual Required – 1 yr. inspection for this facility and was greeted by Caregiver, Etehl Atendito. Administrator, Maria Jasmin Nelson was contacted and arrived later in the visit. The facility currently provides care for 4 residents 3 of which were present, none of which are receiving hospice services or with a diagnosis of dementia.

LPA continued with a tour of the facility with Administrator, 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 Extinguisher was found to be last charged on 5/15/2024. Smoke and carbon monoxide detectors found throughout the facility are interconnected. Local Fire Inspection agency had conducted inspection within the year and scheduled for re-inspection by 12/19/2024 with documentation posted.

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 in locked cabinets under kitchen sinks and garage, 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. Water measured at faucets accessible to residents measured between 115.7 and 116.6 degrees F and is within regulation.

Residents that were present during the inspection were observed returning from day program in their bedroom resting and exercising. The facility encourages regular family visits and utilizes outings for resident activities. There is an outdoor patio with shade and large outdoor space for residents. All residents appear to to have a positive relationship during visit and state that they find the level of care to be adequate.
Continued onto LIC809-C
SUPERVISOR'S NAME: Andrea MedlinTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Dominic TobolaTELEPHONE: (650) 393-9128
LICENSING EVALUATOR SIGNATURE:
DATE: 08/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/08/2024
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: BYXBEE HOME
FACILITY NUMBER: 385600401
VISIT DATE: 08/08/2024
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LPA conducted a sample file review for 4 residents and found all items to be in order. Upon a check for 3 out of 3 staff files, LPA found that caregiver staff have 1st aid and CPR and annual training up to date. In addition, upon a spot check of medications all medication counts and records are in order.

Maria Jasmin Nelson's Administrator Certificate 7023981740 is currently active through 11/24/2024.

LPA requested the following documents be sent to CCL by COB 8/22/2024:

LIC 308 Designated Facility Responsibility
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
LIC 9020 Register of Facility Client’s/Resident’s
Liability Insurance

No deficiencies cited.
SUPERVISOR'S NAME: Andrea MedlinTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Dominic TobolaTELEPHONE: (650) 393-9128
LICENSING EVALUATOR SIGNATURE:

DATE: 08/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2024
LIC809 (FAS) - (06/04)
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