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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 410500567
Report Date: 11/25/2024
Date Signed: 11/25/2024 04:19:06 PM

Document Has Been Signed on 11/25/2024 04:19 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:SEQUOIAS-PORTOLA VALLEY, THEFACILITY NUMBER:
410500567
ADMINISTRATOR/
DIRECTOR:
APRIL THOMPSONFACILITY TYPE:
741
ADDRESS:501 PORTOLA ROADTELEPHONE:
(650) 851-1501
CITY:PORTOLA VALLEYSTATE: CAZIP CODE:
94028
CAPACITY: 328TOTAL ENROLLED CHILDREN: 0CENSUS: 285DATE:
11/25/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:01 AM
MET WITH:David Nelson & Linda WestTIME VISIT/
INSPECTION COMPLETED:
04:20 PM
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On 11/25/2024, LPA Grace Donato made an unannounced annual visit to the facility. LPA met with Clinic Manager David Nelson, Linda West and Gloria Heimlich. LPA explained the purpose of the visit.

LPA toured the facility inside and outside including a random sample of resident rooms, common areas, and kitchen area. Kitchen is located in the independent living building. Food is delivered in assisted living and memory care building. LPA observed residents engaged in different activities. Hot water temperatures were tested at 106 degF. The residents have adequate amount of linens and incontinence care items. All personal belongings are intact. Facility has sprinkler system. All fire extinguishers have been checked and current. Resident bedrooms and bathrooms were observed to be in good repair. Bathrooms are equipped with grab bars and non-skid floors. There is adequate amount of food, 2 days for perishables and & 7 days non-perishable.

Eight resident records and eight staff records were reviewed. Resident records are updated, complete and signed. Staff records are complete. Facility accepts hospice residents and are in compliance with the required waiver requirements. Medication review was done, and all medications are accounted for, and centrally stored medication records are updated.

LPA requested the following documents: LIC500 Personnel Report & Liability Insurance.

No deficiencies are cited at this time. Report is reviewed and a copy is provided.
Andrea MedlinTELEPHONE: (650) 266-8811
Grace DonatoTELEPHONE: (714) 293-8294
DATE: 11/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/25/2024
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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