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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 410507072
Report Date: 01/13/2024
Date Signed: 01/13/2024 02:12:14 PM

Document Has Been Signed on 01/13/2024 02:12 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
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:KAINOS TRIPLEX PLUSFACILITY NUMBER:
410507072
ADMINISTRATOR:FRISCH, ANDREWFACILITY TYPE:
735
ADDRESS:1209 CHANTEL WAYTELEPHONE:
(650) 364-5625
CITY:REDWOOD CITYSTATE: CAZIP CODE:
94061
CAPACITY: 15CENSUS: 15DATE:
01/13/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Administrator Andrew Frisch TIME COMPLETED:
02:30 PM
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Licensing program Analyst (LPA) Jason Lund arrived unannounced to conduct a required/one-year inspection. LPA met with, Administrator Andrew Frisch and explained the purpose of today’s visit. Census:15

LPA Lund & Administrator Andrew Frisch toured/inspected the facility. All outdoor and indoor passageway are free and clear of obstruction. Facility is maintained at a temperature of 70 degrees F. No pools or bodies of water were observed during today's visit. LPA observed at least one week of nonperishable and two (2) days of perishable foods. Toxic chemicals are stored away in a locked cabinet next to the water heater. Centrally stored medications are locked in a cabinet inside the staff room. Each room is equipped with a bed for each resident working lights and a nightstand. Facility has functioning smoke detectors in living room, hallway, and in each resident room. Carbon monoxide detectors are located in the hallways upstairs and downstairs and were tested. Fire extinguishers in the kitchen are full and were last inspected on 6/14/2023.

LPA reviewed four residents’ files. LPA observed signed admission's agreements, signed personal rights statements, completed medical assessment and a completed needs and service plan. medication administration record was reviewed. No errors were observed by LPA.

No deficiencies were cited during today's inspection and exit report given.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE: DATE: 01/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/13/2024
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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