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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385601042
Report Date: 09/20/2024
Date Signed: 09/20/2024 10:56:35 AM

Document Has Been Signed on 09/20/2024 10:56 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:POMEROY RECREATION & REHABILITATION CENTERFACILITY NUMBER:
385601042
ADMINISTRATOR/
DIRECTOR:		HAKALA, PAIVIFACILITY TYPE:
735
ADDRESS:2626 FULTON STTELEPHONE:
(415) 418-3136
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94118
CAPACITY: 6CENSUS: 0DATE:
09/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Mateo Cabrera, Lead Care ProviderTIME VISIT/
INSPECTION COMPLETED:
11:15 AM
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On 9/20/2024, Licensing Program Analyst (LPA) Tobola conducted an unannounced Annual Required – 1 yr. Inspection for this facility and was greeted by Lead Care Provider Staff, Mateo Cabrera. The facility is currently undergoing plumbing renovations since July 2024. The facility provides care for 5 clients, all of which have been safely relocated to either a facility under the same license, Pomerory Recreation & Rehabilitation Center 2, located at 2750 Fulton Street or with family. LPA continued with a tour of the facility with staff. Downstairs common areas, and kitchen areas were inspected. LPA observed several individuals working on plumbing renovations. There are no signs of clients present or residing in the facility at the time of visit. The facility is expected to complete full renovations and accept the relocated clients back by October 2024.

LPA requested the following documents be sent to CCL by COB 10/4/2024:

LIC 308 Designated Facility Responsibility LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan LIC 9020 Register of Facility Client’s/Resident’s
No deficiencies cited.
SUPERVISORS NAME: Andrea Medlin
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE: DATE: 09/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/20/2024
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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