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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 410508733
Report Date: 10/12/2023
Date Signed: 10/12/2023 04:51:34 PM

Document Has Been Signed on 10/12/2023 04:51 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:SOUTH SAN FRANCISCO ADULT DAY CARE CENTERFACILITY NUMBER:
410508733
ADMINISTRATOR:JOSEPH E. HUNZIKERFACILITY TYPE:
775
ADDRESS:601 GRAND AVENUETELEPHONE:
(650) 829-3824
CITY:SOUTH SAN FRANCISCOSTATE: CAZIP CODE:
94080
CAPACITY: 45CENSUS: 2DATE:
10/12/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Kasey CullinanTIME COMPLETED:
10:30 AM
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On 10/12/23 LPA Grace Donato made an unannounced annual visit to the facility. LPA met with Recreation & Community Service Coordinator, Marianna Roman and Recereation & Community Service Supervisor, Kasey Cullinan followed after. LPA explained the purpose of the visit.

Facility has just reopened last 10/2/23. LPA toured the facility inside and outside including all of activity rooms, common areas & kitchen. The indoor and outdoor passageways were free of obstruction. LPA observed two clients doing activities in the activity area, While touring the facility it was observed that the room temperature was at 69 deg F. Hot water is at 118 deg F. All fire extinguishers have been checked and current. Client bathrooms were observed to be in good repair. Food and snacks are provided. No medication in the facility.

Two client records and two staff records were reviewed. Resident records are updated, complete and signed. Staff records are complete, with training logs. Facility has a certified administrator on site with complete certification and training requirements.

LPA requested licensee to submit the following and was received in the facility at 10/12/23:
LIC 500 Personnel Report.

No deficiencies are cited at this time. Report is reviewed and a copy is provided.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE: DATE: 10/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/12/2023
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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