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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 410508554
Report Date: 12/07/2022
Date Signed: 12/07/2022 01:20:08 PM

Document Has Been Signed on 12/07/2022 01:20 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
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:RUSTAN ADULT RESIDENTIAL CARE HOMEFACILITY NUMBER:
410508554
ADMINISTRATOR:LEAH RUIZFACILITY TYPE:
735
ADDRESS:147 PLYMOUTH CIRCLETELEPHONE:
(650) 878-8297
CITY:DALY CITYSTATE: CAZIP CODE:
94015
CAPACITY: 6CENSUS: 0DATE:
12/07/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Son of Licensee, Roderick RuizTIME COMPLETED:
01:20 PM
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 12/7/2022, Licensing Program Analyst (LPA) conducted a case management visit to follow-up on the facility fire incident. Son of Licensee, Roderick Ruiz informed LPA that fire inspection was completed by inspector, Craig Witter this morning and fire clearance was granted.

At 12:45PM, Mr. Ruiz provided a tour of the affected areas ( garage and the living room ceiling) that were affected by the fire. LPA did not observed any residuals from the fire and no signs of smell of smoke. The living ceiling and the garage appeared to be cleaned, and newly painted.

In the garage, LPA observed a new water heater tank, new washer and dryer and new fire rated walls.

In the living room, LPA observed new furniture in boxes and no evidence of ceiling damages due to the fire.

According to Mr. Ruiz, another building inspection will be conducted this afternoon and subsequently, PG & E will turn-on the gas.

The facility is planning to have residents return tomorrow and LPA will conduct a final walk-through after the building inspection and PG & E visit prior to resident's return.

This report is reviewed and discussed with Mr. Ruiz. A copy will be provided.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE: DATE: 12/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/07/2022
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 1