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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 410506148
Report Date: 09/12/2024
Date Signed: 09/12/2024 04:02:14 PM

Document Has Been Signed on 09/12/2024 04:02 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:KAINOS - LA VISTAFACILITY NUMBER:
410506148
ADMINISTRATOR/
DIRECTOR:
ANDREW FRISCHFACILITY TYPE:
735
ADDRESS:3631 JEFFERSON AVENUETELEPHONE:
(650) 363-2427
CITY:REDWOOD CITYSTATE: CAZIP CODE:
94062
CAPACITY: 15CENSUS: 14DATE:
09/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:48 PM
MET WITH:Andrew Frisch, Executive DirectorTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
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On September 12, 2024, Licensing Program Analysts(LPAs) John Calandra and Kiran Jain arrived at the facility at 1:45 PM to complete the Annual 1-year unnanounced required inspection. LPAs Calandra and Jain were greeted by Andrew Frisch, Executive Director and explained the purpose of the visit.

LPAs toured the physical plant. This is a two story building with 9 bedrooms and 4 bathrooms. All bedrooms were observed to have the required furniture and sufficient lighting. The facility's fire extinguishers were last checked on 5/24/2024 and were observed to be fully charged. The facility had night lights in the hallways. The facility's smoke and carbon monoxide alarms were observed to be in working order. The facility had the required 7 days of non perishables and 2 days of perishables on site. No food was expired. Hot water temperature was measured between the required 105-120 degrees Fahrenheit. The First Aid kit had all the required articles.

LPAs reviewed 5 resident files and 6 staff files. All were observed to be complete.

LPAs also reviewed Personal and Incidental (P&I) monies kept at the facility which matched the facility records.

LPAs Calandra and Jain reviewed Centrally Stored Medications Records(CSMR). A review of Centrally stored medications indicated that medications for residents were properly labeled with instructions on dosage and times of day and matched the Centrally Stored Medication Records(CSMR) kept at the facility.\

No deficiencies were cited during today's visit.

An exit interview was conducted. This report was reviewed with Andrew Frisch, Executive Director and a copy of the report left at the facility.
SUPERVISORS NAME: Andrea Medlin
LICENSING EVALUATOR NAME: John Calandra
LICENSING EVALUATOR SIGNATURE: DATE: 09/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/12/2024
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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