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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 410508749
Report Date: 03/19/2025
Date Signed: 03/19/2025 12:46:57 PM

Document Has Been Signed on 03/19/2025 12:46 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/
DIRECTOR:
NINA ALIASONFACILITY TYPE:
735
ADDRESS:744 SKYLINE DRIVETELEPHONE:
(650) 878-5964
CITY:DALY CITYSTATE: CAZIP CODE:
94015
CAPACITY: 6CENSUS: 4DATE:
03/19/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:48 AM
MET WITH:Administrator, Nina AliasonTIME VISIT/
INSPECTION COMPLETED:
12:59 PM
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On March 19, 2025, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced annual visit. LPA met with Administrator, Nina Aliason and explained the purpose of the visit.

LPA toured the facility inside and outside including all of resident rooms, common areas & kitchen. The indoor and outdoor passageway was free of obstruction. No accessible bodies of water of fire safety hazards observed. This is a single floored facility. There are three resident bedrooms; all of which were shared rooms, one staff bedroom and two full bathrooms. Resident rooms were observed to be clean with all required furniture. Bathrooms were observed to be clean, odor-free and in good repair. Water temperature throughout the facility was within regulatory requirements. Extra linen was observed to be present. First aid kit was observed to be complete.

Dining room was observed free from tripping hazards. A comfortable temperature is maintained and lighting is sufficient for comfort. LPA observed two day perishables and seven day non-perishables. Extra food supply was observed to be present. Medications, sharps, and chemicals were observed locked an inaccessible to residents in care.

Carbon monoxide monitors are working properly. All fire extinguishers have been checked and current as of
April 2024. Emergency drills are logged and done every three month. LPA reviewed 4 resident records and 4 staff records. Resident records are updated, complete and signed. Staff records are complete, with training logs that have met the basic requirement. Medication review was done, and all medications are accounted for, and centrally stored medication records are updated.

No citations are issued during this visit. Report is reviewed with Administrator and a copy is provided.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE: DATE: 03/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/19/2025
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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