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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 410508725
Report Date: 01/10/2024
Date Signed: 01/10/2024 05:56:20 PM

Document Has Been Signed on 01/10/2024 05:56 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:C AND Z RESIDENTIAL CAREFACILITY NUMBER:
410508725
ADMINISTRATOR:HERRERA, CESAR DE JESUSFACILITY TYPE:
735
ADDRESS:636 SOUTHMOOR DRIVETELEPHONE:
(650) 355-3317
CITY:PACIFICASTATE: CAZIP CODE:
94044
CAPACITY: 10CENSUS: 8DATE:
01/10/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:51 AM
MET WITH:Mayra Herrera TIME COMPLETED:
12:40 PM
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On January 10, 2024, Licensing Program Analyst(LPA) John Calandra arrived at the facility at 8:51 AM to conduct an unannounced Annual 1-year required inspection. LPA Calandra met with Mayra Herrera and Cesar Herrera, Administrators and explained the purpose of his visit.

LPA Calandra toured the physical plant. This is a two story building that consists of 7 bedrooms(5 for residents and 2 staff bedrooms) and 2 bathrooms. Water in all bathrooms was measured between the required 105-120 degrees Fahrenheit. Bathrooms were observed to have the required grab bars and anti-skid mats. Fire extinguisher in the facility was observed to be fully charged and last checked on 1/10/2023. The facility had the required 7 days of non-perishables and 2 days of perishables on site. No food was expired. The kitchen and garage refrigerators and freezers temperature was within the required range. All bedrooms were sufficiently lit and had the required furniture. The front and backyards were clear from obstructions. No accessible bodies of water or hazards were observed. The facility's first aid was observed to be complete. There were 3 staff and no residents present during the inspection.

P and I money was counted in the presence of the LPA and matched facility records.

All knives and sharp objects were observed to be locked and in-accessible to persons in care.

All medications, soaps, and detergents were observed to be locked and in-accessible to persons in care.

A review of Centrally stored medications indicated that medications for residents were properly labeled with instructions on dosage and times of day and matched the Centrally Stored Medication records kept at the facility.

LPA Calandra reviewed 5 resident records. All were observed to be complete.

LPA also reviewed 3 staff records. All were observed to be complete.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: John Calandra
LICENSING EVALUATOR SIGNATURE: DATE: 01/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/10/2024
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: C AND Z RESIDENTIAL CARE
FACILITY NUMBER: 410508725
VISIT DATE: 01/10/2024
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The following documents were received at the facility:

-LIC 309(Administrative Organization)
- Health Screening Reports
-Administrative Certificates
-LIC 610E


No interviews were completed today.

The Annual will be completed at a later date.

No deficiencies were cited during today's visit. This report was reviewed with Mayra Herrera and Cesar Herrera, Administrators and a copy left at the facility.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: John Calandra
LICENSING EVALUATOR SIGNATURE:

DATE: 01/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2024
LIC809 (FAS) - (06/04)
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