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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 410508505
Report Date: 09/20/2024
Date Signed: 09/20/2024 01:41:14 PM


Document Has Been Signed on 09/20/2024 01:41 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:SANTA BARBARA GUEST HOME FOR THE ELDERLYFACILITY NUMBER:
410508505
ADMINISTRATOR:PRIMUS, OLIVIAFACILITY TYPE:
740
ADDRESS:420 SANTA BARBARA AVE.TELEPHONE:
(650) 992-2159
CITY:DALY CITYSTATE: CAZIP CODE:
94014
CAPACITY:6CENSUS: 0DATE:
09/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:20 PM
MET WITH:Valerie Primus, AdministratorTIME COMPLETED:
02:00 PM
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On September 20, 2024, Licensing Program Analysts (LPAs) Kiran Jain and Komal Charitra arrived at the facility at 12:20 PM to conduct the Annual 1-year required inspection. LPAs met with Valerie Primus, Administrator and explained the purpose of the visit.

LPAs toured the physical plant and observed it to be odor-free at a comfortable temperature. LPAs observed that there are currently no residents at the facility. Facility is currently not operational. This is a two-story building with 3 shared resident bedrooms, 1 bathroom, a living room with dining, and the kitchen on the main level. The lower level has a garage with a washer and dryer for the laundry. No accessible bodies of water or hazards were observed. The fire extinguisher was fully charged and last serviced on 06/06/2024. The smoke detector and carbon monoxide detector were fully operational.

LPAs inspected all three rooms and one bathroom. Rooms were observed to be have the required furniture and sufficient lighting. The hot water temperature in the bathroom sink faucet was measured at 117.1°F.



Sharp objects, detergents, poisons, and chemicals were observed to be locked. There are no resident's files or medications to review. LPAs observed a cabinet to keep medications locked. First Aid kit was present and complete. There were no emergency drill logs to review, as the facility is not housing any residents.

LPAs observed that facility license and Administrator certificate posted and is current.



No deficiencies were cited during today's visit.

An exit interview was conducted. This report was reviewed with Valerie Primus, Administrator, and a copy of this report was left at the facility.
SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Kiran JainTELEPHONE: 650-416-4836
LICENSING EVALUATOR SIGNATURE:
DATE: 09/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/20/2024
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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