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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 410508749
Report Date: 10/05/2023
Date Signed: 10/05/2023 02:53:51 PM

Document Has Been Signed on 10/05/2023 02:53 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 #2FACILITY NUMBER:
410508749
ADMINISTRATOR:NINA ALIASONFACILITY TYPE:
735
ADDRESS:744 SKYLINE DRIVETELEPHONE:
(650) 878-5964
CITY:DALY CITYSTATE: CAZIP CODE:
94015
CAPACITY: 6CENSUS: 6DATE:
10/05/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Elvira Cano, Caregiver and Nina Alliason, AdministratorTIME COMPLETED:
03:15 PM
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On October 5, 2023, Licensing Program Analyst, John Calandra and Licensing Program Manager, Cara Smith arrived at the licensed facility for a follow up visit in regards to an incident report received on 8/14/2023. LPA Calandra and LPM Smith were greeted at the door by Elvira Cano, Caregiver and they explained the purpose of their visit.

LPA Calandra and LPM Smith were given a tour of the facility by Caretaker, Elvira which included three client bedrooms, 2 bathrooms (1 upstairs and 1 downstairs), the kitchen, living room, etc. Nina Allison, was able to join via phone. LPA Calandra and LPM Smith reviewed client records of R1, R2, and R3. LPA Calandra and LPM Smith asked for copies of Nina's administrator certificate, LIC 500, etc. and for her to check Guardian as CCLD only has two staff members currently associated with the facility.

The administrator, Nina stated that R1, his social worker, Anita Yen and Nina had a discussed the incident on Zoom on 10/3/2023 and investigation revealed that R2 puts his arm on R1 when he is in need of postural support due to a medical condition. Since the incident, the administrator stated that R1 and R2 who were previously roommates are no longer roommates and have switched with other clients and no other incidents have been reported.

An exit interview was conducted with Elvira Cano, Caretaker and a copy of the report was left at the facility. No other deficiencies were cited today.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: John Calandra
LICENSING EVALUATOR SIGNATURE: DATE: 10/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/05/2023
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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