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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 410508749
Report Date: 04/25/2023
Date Signed: 04/25/2023 03:10:00 PM

Document Has Been Signed on 04/25/2023 03:10 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:CARING HEARTS HOME #2FACILITY NUMBER:
410508749
ADMINISTRATOR:NINA ALIASONFACILITY TYPE:
735
ADDRESS:744 SKYLINE DRIVETELEPHONE:
(650) 878-5964
CITY:DALY CITYSTATE: CAZIP CODE:
94015
CAPACITY: 6CENSUS: 6DATE:
04/25/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Administrator, Nina AliasonTIME COMPLETED:
11:40 AM
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 4/25/2023, Licensing Program Analyst(LPA) Murial Han conducted an unannounced annual inspection. LPA observed COVID-19 signs posted by the entrance. LPA was greeted by administrator and LPA explained the purpose of the visit.

The administrator assisted with the inspection.

LPA toured the facility inside and outside including the 4 bedrooms (3 semi-private rooms for clients and 1 private room for staff) 1 full- bathroom , kitchen, and common areas. The facility observed to clean, tidy and in good repair. Bedrooms were equipped with the required furniture for clients to use. Bathrooms are equipped with grab bars, and nonskid mats. COVID-19 signs were posted throughout the facility. Facility temperature is comfortable. Hot water temperature was measured at 106-112 degrees F. The Atrium/Activities room was observed to comfortable, and cozy for clients to enjoy.

Central stored medication, toxins and sharps objects were locked and inaccessible to clients.

Food supplies were observed to be adequate,

Facility is equipped with smoke detectors and carbon monoxide detectors. Fire extinguisher was last serviced on April 7 2023 and fire drill was last conducted on 2/21/23 and it is being done quarterly.

Staff member at the facility was fingerprint and associated.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE: DATE: 04/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/25/2023
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
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: CARING HEARTS HOME #2
FACILITY NUMBER: 410508749
VISIT DATE: 04/25/2023
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
26
27
28
29
30
31
32
LPA reviewed clients and staff records. Client records contain admission agreement, medical assessment, LIC 602 (Physician Order), Appraisal Needs and Service Plan, GGRC/IPP, etc.

Staff files contain personnel records, health screening, COVID-19 vaccination card, Job Description, Abuse Statement, First Aide and CPR, Criminal Record Statement.

LPA reviewed the P & I records and receipts for 5 clients.

During today's inspection, there are 6 clients present.

No deficiency cited today.

This report is reviewed and discussed with the administrator.

A copy is provided.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:

DATE: 04/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2