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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385600450
Report Date: 12/18/2024
Date Signed: 12/18/2024 12:26:30 PM

Document Has Been Signed on 12/18/2024 12:26 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:ROBERTSON PLACEFACILITY NUMBER:
385600450
ADMINISTRATOR/
DIRECTOR:
JOSE TREVINOFACILITY TYPE:
772
ADDRESS:921 LINCOLN WAYTELEPHONE:
(415) 664-1414
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94122
CAPACITY: 12CENSUS: 10DATE:
12/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Joel Martin-Dill, Councilor & Sherina Thomas, Program DirectorTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
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On 12/18/2024, Licensing Program Analyst (LPA) Dominic Tobola conducted an unannounced annual inspection and was greeted by Councilor, Joel Martin-Dill. Program Director, Sherina Thomas was contacted and arrived later in the visit. Facility is a three story building that provides care for 10 clients, all of which are ambulatory and some of which were present during the inspection.

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. Client’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguishers were found in the kitchen and throughout each facility floor were charged. Carbon monoxide detectors were tested in client bedrooms and hallways throughout the facility and found to be in working order. Exit stairways were found to be free from any hazards.

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 clients in care. There was a supply of hygiene products and paper products available for clients. All client’s bedrooms have lighting & appropriate furnishings and bedding items. The facility provides group program from 9:00am - 2:00pm with a designated multipurpose common space and renovated out patio space for client use. Staff provide program support on acquiring housing, benefits and career options for clients to successfully transition to independent living. Clients were observed to have a positive relationship with staff with treatment involvement and level of care found to be exceptional. Upon review of client records, LPA found all items to be in order including medical assessments and intake appraisals.

No deficiencies cited.

LPA Requested for the following items to be submitted to CCLD by 1/10/2025:
LIC 308 Designated Facility Responsibility LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
SUPERVISORS NAME: Andrea Medlin
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE: DATE: 12/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/18/2024
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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