<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 410508402
Report Date: 07/03/2024
Date Signed: 07/03/2024 10:28:37 AM


Document Has Been Signed on 07/03/2024 10:28 AM - 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:B & B RESIDENTIAL FACILITIESFACILITY NUMBER:
410508402
ADMINISTRATOR:BULJAN, ANTE & SLAVAFACILITY TYPE:
740
ADDRESS:13 W. 38TH AVENUETELEPHONE:
(650) 570-5124
CITY:SAN MATEOSTATE: CAZIP CODE:
94403
CAPACITY:6CENSUS: 4DATE:
07/03/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Administrator - Noralee ReyesTIME COMPLETED:
10:35 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 07/03/2024, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced annual inspection. LPA met with administrator Noralee Reyes and explained the purpose of today's visit. There is 3 staff present and 4 residents present.

LPA was allowed entry into the facility. This is a multilevel facility but the residents only reside on the main floor where the front door is located. The upper and ground floors are rented out to private renters. Renters do not have access to the residents in the facility. Annual fees are current. The physical plant was toured inside and outside to ensure the safety of the residents. LPA observed the facility kitchen which is clean and observed appliances are in good repair. Knives are stored and locked in the kitchen in a drawer adjacent to the stove top. Medications are also locked in a lower kitchen in a cabinet. Perishable and non-perishable food items are observed as in place. There are additional refrigerators and freezers in the garage areas which also carry additional food supplies. First aid kit is observed as complete with required items. LPA observed that there are multiple fire extinguishers in place inspected 06/27/2023, smoke detector/carbon monoxide detectors are observed in place through out the facility, and central heating/cooling system. PPE and additional food supplies are observed as in place. Laundry area is also observed as fully operational located beneath the facility. Emergency exit routes are observed inside and outside to be free and clear of obstructions. Last emergency/disaster drill was conducted on 04/17/2024. Water temperature was measured at 107F. Shower floor uses non-skid mat when shower is in use. LPA observed rooms at random and all appeared clean, free of odors, and contained all the required furniture per regulatory recommendations. Resident linen supplies are observed as in place.

Continued on next page...
SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8865
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:
DATE: 07/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/03/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: B & B RESIDENTIAL FACILITIES
FACILITY NUMBER: 410508402
VISIT DATE: 07/03/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Page 2

LPA reviewed 2 client files and also reviewed 3 staff files on this day. Per resident files reviewed they are current. Per staff files reviewed all files were current with training and CPR/First Aid. P&I is not handled by the facility. Client medications are inspected and are current including facility medication administration records. Administrator certificate is observed as current expiring on 09/24/2025.

The following updated forms are requested to be submitted to CCLD by 07/10/2024:

• Copy of updated Administrator Certificates
• LIC308 Designation of responsible staff person
• LIC400 Affidavit Regarding Client/Resident Cash Resources
• LIC610E Emergency Disaster Plan
• LIC500 Staff Schedule
• Copy of control of property

No citations issued on this day. Report is reviewed with Noralee and a copy is provided.
SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8865
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:

DATE: 07/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2