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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 410508749
Report Date: 03/28/2024
Date Signed: 03/28/2024 04:09:48 PM

Document Has Been Signed on 03/28/2024 04:09 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:
03/28/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:05 PM
MET WITH:Elvira Cano, DSP and Nina Allison, Administrator TIME COMPLETED:
04:15 PM
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On March 28, 2024 at 1:05 PM, Licensing Program Analyst(LPA) John Calandra arrived at the facility, to conduct the Annual 1-year required inspection. LPA Calandra was greeted by Elvira Cano, Direct Support Professional, and explained the purpose of his visit. Nina Aliason, Administrator, arrived later during the visit.

LPA Calandra took a tour of the physical plant. This is a one story building with 4 bedrooms (3 resident bedrooms and 1 staff bedroom) and 2 bathrooms. Hot water in all bathrooms was measured within the required 105-120 degrees Fahrenheit (118.4 and 118.9). No accessible bodies of water or hazards were observed in the hallways or back and front yards. Fire Extinguishers were observed to be fully charged and last checked on April 7, 2023. The facility was maintained at a comfortable temperature of 69.8 degrees Fahrenheit. The facility Carbon Monoxide and Fire Alarms were observed to be in working order except one in the facility's Atrium. LPA observed Administrator, Nina Aliason reaching out to her contractor to schedule a date for him to come to the facility to fix it. The facility has the required 7 days of non-perishables and 2 days of perishables on hand. No expired food was observed. The facility refrigerator and freezers' temperature was within the required range. The facility washer was observed to be in working condition however, the facility dryer is non-operational at this time.

All Personal and Incidental(P&I) monies were accounted for.

During the visit, LPA Calandra requested and received the following documents:

-Health Screening Reports
-LIC 309-Administrative Organization

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(CSMR) kept at the facility.

SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: John Calandra
LICENSING EVALUATOR SIGNATURE: DATE: 03/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/28/2024
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: CARING HEARTS HOME #2
FACILITY NUMBER: 410508749
VISIT DATE: 03/28/2024
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Sharp objects, detergents, and poisons were observed to be locked and in accessible to persons in care.

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

The Annual will be completed at a later date.

A Technical Violation was provided for the dryer as it is not currently in good repair.

No deficiencies were cited during today's visit.

This report was reviewed with Nina Aliason, Administrator and a copy of the report left at the facility.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: John Calandra
LICENSING EVALUATOR SIGNATURE:

DATE: 03/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2024
LIC809 (FAS) - (06/04)
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