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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 410508807
Report Date: 01/08/2025
Date Signed: 01/08/2025 10:54:14 AM

Document Has Been Signed on 01/08/2025 10:54 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/
DIRECTOR:
DIAZ, ESTELA AND MARIAFACILITY TYPE:
735
ADDRESS:1959 JEFFERSON AVENUETELEPHONE:
(650) 361-8122
CITY:REDWOOD CITYSTATE: CAZIP CODE:
94062
CAPACITY: 6CENSUS: 1DATE:
01/08/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Estela Diaz, Administrator/LicenseeTIME VISIT/
INSPECTION COMPLETED:
11:00 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 1/8/2025, Licensing Program Analyst(LPA) John Calandra arrived at the facility at 8:30 AM to conduct the Annual 1-year required inspection. LPA Calandra was greeted by Stella Diaz-Calder, Administrator/Licensee and explained the purpose of the visit.

LPA toured the physical plant. This is a 1-story building with 5 bedrooms (4 for residents and 1 for staff), 2 and a half bathrooms, kitchen, office, backyard, living room, and dining room. All bedrooms had the required furniture and sufficient lighting. The facility's hot water temperature was measured within the required 105-120 degrees Fahrenheit. The facility was maintained at a comfortable temperature. The facility's fire alarms and carbon monoxide detectors were observed to be in working order. The facility's first aid kit had all the required items. The facility had the required 7 days of non perishables and 2 days of perishables on hand. No food was expired.

All sharp objects, detergents, poisons, etc. were observed to be locked and in-accessible to persons in care.
During the visit, LPA collected the following documents:
  • Administrator Certificate
  • Current LIC 500

LPA Calandra reviewed 1 resident file and 4 staff files. All were observed to be complete.

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 kept at the facility.

No deficiencies were cited during today's visit.

An exit interview was conducted. This report was reviewed with Stella Diaz-Calder, Administrator/Licensee and a copy of the report left at the facility.
SUPERVISORS NAME: Andrea Medlin
LICENSING EVALUATOR NAME: John Calandra
LICENSING EVALUATOR SIGNATURE: DATE: 01/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/08/2025
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 1