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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 410500325
Report Date: 10/15/2024
Date Signed: 10/15/2024 12:40:32 PM

Document Has Been Signed on 10/15/2024 12:40 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:FHAR - HORIZON HOMEFACILITY NUMBER:
410500325
ADMINISTRATOR/
DIRECTOR:
MCKIBBEN, LISAFACILITY TYPE:
735
ADDRESS:901 NORTH ROADTELEPHONE:
(650) 593-2669
CITY:BELMONTSTATE: CAZIP CODE:
94002
CAPACITY: 8CENSUS: 7DATE:
10/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Administrator, Lisa MckibbenTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
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On October 15, 2024, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced annual visit. LPA met with Administrator, Lisa Mckibben and explained the purpose of the visit.

LPA toured the facility inside and outside including but not limited to all of client rooms, garage, bathrooms, common areas & kitchen. The indoor and outdoor passageways were free of obstruction. No accessible bodies of water of fire safety hazards observed. LPA observed four client bedrooms; all of which are shared rooms. Rooms were observed clean, in good repair with all required furniture. LPA observed three full bathrooms; equipped with liquid soap, paper towels, and non-skid mats. Office room was toured. LPA observed medications and chemicals locked and inaccessible to clients in care. Extra linen and first aid kit was present. Water temperature throughout the facility measured between 106-117 degrees F.

Living room and dining room were observed free from tripping hazards. A comfortable temperature is maintained and lighting is sufficient for comfort. LPA toured kitchen and observed two day perishable and seven day non-perishables. Sharps were observed to be locked an inaccessible to clients. Carbon monoxide monitors are working properly. All fire extinguishers have been checked and current as of May 2024. Emergency drills are logged and done every month.

LPA reviewed 5 client records and 4 staff records. Client records are updated, complete and signed. Staff records are complete, with training logs that have met the basic requirement. Medication review was done, and all medications are accounted for, and centrally stored medication records are updated.

No citations are issued during the visit. Report is reviewed with the administrator and a copy is provided.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE: DATE: 10/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/15/2024
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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