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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385600430
Report Date: 02/11/2021
Date Signed: 08/01/2023 11:51:45 AM


Document Has Been Signed on 08/01/2023 11:51 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
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066



FACILITY NAME:CYPRESS AT GOLDEN GATEFACILITY NUMBER:
385600430
ADMINISTRATOR:TAZAWA, KATHERINEFACILITY TYPE:
740
ADDRESS:1601 19TH AVENUETELEPHONE:
(415) 664-6264
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94122
CAPACITY:138CENSUS: 91DATE:
02/11/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Executive Director, Katherine Tazawa and Enliven Director, Daisy DizonTIME COMPLETED:
05:00 PM
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On 2/11/2021, LPA Han conducted an unannounced Case Management Inspection in response to an incident that was reported by the facility on 2/4/2021. Resident #1 (R1) was found by staff sitting on the bed with scratches.

Due to the Pandemic, LPA Han has conducted this inspection remotely.

LPA Han spoke to the Executive Director, Katherine Tazawa and the Enliven Director, Daisy Dizon regarding the incident and requested for the following documents:

- Most recent Physician Report
- Current Service Plan
- Updated Reassessment
- Update Service Plan when available
- Medical Records
- Any relevant facility records pertaining to the incident

Ms. Tazawa stated that the above reports will be provided to San Bruno Licensing Office by 2/15/2021

LPA Han has reviewed this report with the Administrator, Katherine Tazawa and will provide this report to her for signature.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:
DATE: 02/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/11/2021
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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