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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 410508725
Report Date: 10/24/2024
Date Signed: 10/24/2024 03:06:02 PM

Document Has Been Signed on 10/24/2024 03:06 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/
DIRECTOR:
HERRERA, CESAR DE JESUSFACILITY TYPE:
735
ADDRESS:636 SOUTHMOOR DRIVETELEPHONE:
(650) 355-3317
CITY:PACIFICASTATE: CAZIP CODE:
94044
CAPACITY: 10CENSUS: 8DATE:
10/24/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:47 PM
MET WITH:Mayra Cesar De Jesus Herrera, LicenseeTIME VISIT/
INSPECTION COMPLETED:
03:20 PM
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On 10/24/2024, Licensing Program Analyst(LPA) Dominic Tobola conducted an unannounced annual inspection and was greeted by Licensee Mayra and Cesar De Jesus Herrera. Facility provides care for 8 clients all of which were attending day program or returning home at the time of visit.

LPA continued with a tour of the facility with staff, facility found to be clean and at a comfortable temperature with all exits free from obstruction. Client’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguishers were found in the kitchen and upstairs living room area were charged. Smoke and carbon monoxide detectors were found to be in working order.

There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations, with food stored in the kitchen refrigerator found to have appropriate coverings, enough for clients in care. There was a supply of hygiene products and paper products available for clients. All client’s bedrooms have lighting & appropriate furnishings and bedding items.

All 8 clients attend day program Monday through Friday with transportation provided. The facility provides various outings in the community, several parks, beaches and shopping centers. Clients are also encouraged to visit friends and family and engage in the community. There is an outdoor patio that is equipped with shade with sufficient space for client use and a sufficient amount of activity supplies.

A spot check of medications was conducted and found all records and medication count to be in order. Upon review of client records, LPA found that all items are updated. Upon spot review of staff records, LPA found that all staff have updated 1st aid & CPR certification and training records completion. Lastly, P&I monies were reviewed, not commingled and accurate to fund ledgers.

LPA Requested for the following items to be submitted to CCLD by 11/7/2024:
LIC 308 Designated Facility Responsibility
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan

No deficiencies cited during todays visit.
SUPERVISORS NAME: Andrea Medlin
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE: DATE: 10/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/24/2024
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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