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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 410507207
Report Date: 11/05/2024
Date Signed: 11/05/2024 04:29:53 PM

Document Has Been Signed on 11/05/2024 04:29 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:P.A.R.C.A. CEDAR STREET HOUSEFACILITY NUMBER:
410507207
ADMINISTRATOR/
DIRECTOR:
CARLETTE L PHIPPSFACILITY TYPE:
735
ADDRESS:721 CEDAR STREETTELEPHONE:
(650) 226-3798
CITY:SAN CARLOSSTATE: CAZIP CODE:
94070
CAPACITY: 8CENSUS: 6DATE:
11/05/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:42 PM
MET WITH:Roxanne Pedro, Direct Support Professional TIME VISIT/
INSPECTION COMPLETED:
04:30 PM
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On November 5, 2024, Licensing Program Analyst (LPA) John Calandra arrived at the facility at 3:42 PM to conducted an unannounced Case Management visit for a Health and Safety Check. Purpose of visit is due to a self reported incident by the facility on 10/30/2024. LPA met with caregiver, Roxanne Pedro.

During today's visit, LPA toured the facility with caregiver and observed facility to be clean and tidy and
residents to be calm and comfortable. The facility was maintained at a comfortable temperature of 72
degrees Fahrenheit. Hot water temperature was measured within the required range of 105-120 degrees Fahrenheit. The facility had the required 7 days of non perishables and 2 days of perishables. No food was expired. The facility had the required grab bars and anti-skid flooring. All bedrooms had the required furniture and sufficient lighting. No accessible bodies of water or hazards were observed in hallways or the backyard.

Based on the information obtained in the self reported unusual incident report, the following is being requested of the facility:

During today’s visit Licensing requested the following documents by Friday, November 8th, 2024:
· SOC 341-Report of Suspected Dependent Adult/Elder Abuse
· Copies of Internal staff training that facility has stated they have conducted – this shall include the topics discussed, the training agenda, the date of training(s), which staff attended, sign in/out log to verify attendance
· Copies of all cross reports facility states they have made
· Any extra services that facility has offered to anyone who may have needed support related to incident

An exit interview was conducted. This report is reviewed and discussed with the Caregiver, Roxanne Pedro; A copy is provided.





SUPERVISORS NAME: Andrea Medlin
LICENSING EVALUATOR NAME: John Calandra
LICENSING EVALUATOR SIGNATURE: DATE: 11/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/05/2024
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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