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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 410508807
Report Date: 01/23/2024
Date Signed: 01/23/2024 11:23:46 AM

Document Has Been Signed on 01/23/2024 11:23 AM - 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:JEFFERSON PLACEFACILITY NUMBER:
410508807
ADMINISTRATOR:DIAZ, ESTELA AND MARIAFACILITY TYPE:
735
ADDRESS:1959 JEFFERSON AVENUETELEPHONE:
(650) 361-8122
CITY:REDWOOD CITYSTATE: CAZIP CODE:
94062
CAPACITY: 6CENSUS: 1DATE:
01/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Licensee Stella CalderTIME COMPLETED:
11:30 AM
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On 01/23/2024, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced required 1 year annual inspection visit. LPA met with licensee Stella Calder and explained the purpose of today's visit.

LPA was allowed entry into the facility. The facility began floor repairs on this day and is only expecting for the repairs to last today and tomorrow. The flooring is in place but only repairs are being done, not removal. This is a one level facility. Annual Fees are current. The physical plant was toured inside and outside to ensure the safety of the resident. LPA observed the facility kitchen which is clean and observed appliances are in good repair. Knives are stored in the kitchen locked in a drawer adjacent to the sink. Cleaning solutions are also locked below the sink. Perishable and non-perishable food items are observed as in place. The first aid kit observed as complete with required items. LPA observed that the facility is equipped with three fire extinguishers that are placed through out the facility last being inspected on 12/05/23, smoke detector/carbon monoxide detectors are observed in place, and central heating system. Laundry area is also observed as fully operational located in the garage. Emergency exit routes are observed inside and outside to be free and clear of obstructions. Water temperature was measured at 111F. This facility currently only has one resident who is at day program on during this inspection visit. Their room is observed as being clean, free of odors, and contained all the required furniture per regulatory recommendations. Cleaning supplies are observed being locked in a hallway closet adjacent to the kitchen. Sharps and medications are both locked in the kitchen in drawers separate from each other. COVID PPE and resident incontinence supplies are observed as in place. Facility added the ADA door and lift to the facility floor plan. The door is located in the living room area near the kitchen.

Resident file and staff files are reviewed and are current. The facility does handle the resident monies and it is inspected as being accurate. Licensee administrator certificate is observed as expiring on 03/22/2024.

The following updated documents are requested to be received by 01/30/2024:

• LIC610D Emergency Disaster Plan
• LIC 308 Designation of Administrative Responsibility
• LIC 500 Personnel Report
• Copy of administrator certificate
• LIC9020 Client Roster
• Certificate of Liability Insurance
• Updated facility floor plan

Report is reviewed with Stella. No citations issued.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Jaime Vado
LICENSING EVALUATOR SIGNATURE: DATE: 01/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/23/2024
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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