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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 410508906
Report Date: 07/31/2024
Date Signed: 07/31/2024 04:47:25 PM

Document Has Been Signed on 07/31/2024 04:47 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:GRACIOUS MANORFACILITY NUMBER:
410508906
ADMINISTRATOR/
DIRECTOR:
NOVICIO, MONETTEFACILITY TYPE:
735
ADDRESS:3030 MEDINA DRIVETELEPHONE:
(650) 589-7292
CITY:SAN BRUNOSTATE: CAZIP CODE:
94066
CAPACITY: 6CENSUS: 5DATE:
07/31/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:20 AM
MET WITH:Caregiver, Maria VelascoTIME VISIT/
INSPECTION COMPLETED:
12:10 PM
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On July 31, 2024, Licensing Program Analyst(LPA) Murial Han conducted an unannounced annual inspection. Upon entrance, LPA was greeted by the caregiver, Maria Velasco and LPA explained of today's visit. The administrator, Monette arrived during the inspection and LPA explained the purpose of the visit.

LPA toured facility and grounds. No accessible bodies of water or fire safety hazards observed. LPA toured the facility inside and outside including all of resident rooms, common areas, and kitchen area. The indoor and outdoor passageways were free of obstruction. Facility was overall clean and odor-free. Comfortable temperature is maintained and lighting is sufficient for comfort.

LPA observed four shared rooms (3 rooms for residents and 1 room for staff). Rooms were spacious and included all required furnishings. Two full bathrooms were observed to be clean and in operating condition. Hot water temperature was measured at 106- 119 F.

LPA observed medications, toxins and sharps to be locked and inaccessible to residents in care. 2 days for perishables and & 7 days non-perishable were observed to be present.

Emergency drill records were reviewed.

A review of (5) resident files was conducted and noted on the LIC 858.
A review of (2) staff files was conducted and noted on the LIC 859.

LPA reviewed P& I records for 3 residents to be adequate.

LPA requested for documents to be submitted to CCL by 8/1/2024: LIC 400, Liability Insurance, proof of administrator certification renewal, and control of property/ lease agreement.

No deficiency cited today.

This report is reviewed and discussed with the administrator. A copy is provided.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE: DATE: 07/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/31/2024
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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