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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 410508608
Report Date: 09/17/2024
Date Signed: 09/17/2024 04:57:33 PM

Document Has Been Signed on 09/17/2024 04:57 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:CARING HEARTS HOME #1FACILITY NUMBER:
410508608
ADMINISTRATOR/
DIRECTOR:
NINA ALIASONFACILITY TYPE:
735
ADDRESS:927 CRANE AVENUETELEPHONE:
(650) 571-8994
CITY:FOSTER CITYSTATE: CAZIP CODE:
94404
CAPACITY: 6CENSUS: 4DATE:
09/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Caregiver, Angelina CruzTIME VISIT/
INSPECTION COMPLETED:
10:35 AM
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On September 17, 2024 Licensing Program Analyst (LPA) Murial Han conducted an unannounced annual inspection. LPA met with caregiver, Angelina Cruz and LPA explained the purpose of today's visit.

LPA toured the facility inside out and inspected the living room, dining area, kitchen, bedrooms, bathrooms, garage and backyard. This is a single story home with 3 resident bedrooms, 2 full bathrooms, and two staff rooms. The indoor and outdoor passageways were free of obstruction. Furniture and furnishings were observed to be sufficient. Food supplies were sufficient of 2- days perishables and 7- days of non-perishables. Toilet, hand washing and bathing areas were observed clean and in operating condition. Showers were observed equipped with non-skid mats and grab bars. Comfortable temperature is maintained and lighting is sufficient for comfort.
Bed sheets, linens, and towels were observed to be sufficient and able to meet the needs of the residents at this time.
Central storage for medications, sharps and chemicals were observed to be locked and inaccessible to residents in care.
Hot water temperature in the kitchen and bathroom were measured at 111-118 degrees Fahrenheit. Fire extinguishers were checked and last inspected on 4/29/2024.
P & I were reviewed.
A review of (4) resident files was conducted and noted on the LIC 858.
A review of (2) staff files was conducted and noted on the LIC 859.

No deficiency is cited today; this report is reviewed and discussed with caregiver; a copy is provided.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE: DATE: 09/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/17/2024
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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