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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415201955
Report Date: 04/24/2024
Date Signed: 04/24/2024 11:48:13 AM


Document Has Been Signed on 04/24/2024 11:48 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:SENIORS WITH GRACE CARE HOMEFACILITY NUMBER:
415201955
ADMINISTRATOR:MANUEL, GRACEFACILITY TYPE:
740
ADDRESS:167 ALAMEDA DE LAS PULGASTELEPHONE:
(650) 369-5070
CITY:REDWOOD CITYSTATE: CAZIP CODE:
94062
CAPACITY:6CENSUS: 6DATE:
04/24/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Administrator/Licensee - Grace ManuelTIME COMPLETED:
12:00 PM
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On this day, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced required 1 year annual inspection visit. LPA met with licensee/administrator Grace Maneul and explained the purpose of today's visit.

Prior to entry LPA observed that the exterior of the facility is undergoing renovations/painting. No walkways are obstructed prior to entry. No renovations are taking place inside the facility that may affect residents in care. LPA was allowed entry to the facility. This is a single level facility and is licensed to serve 6 residents all of whom may be non-ambulatory. Facility has a hospice waiver on file for 4 residents. There are 2 residents on hospice during today's visit. Annual Fees are current. The physical plant is toured inside and outside to ensure the safety of the residents. During today's visit LPA observed all residents, one of which was still sleeping in bed, and the rest are in common areas. LPA observed the facility kitchen which is located adjacent to the dining room. Knives are stored within the kitchen in a cabinet adjacent to the sink. Medication cabinet is observed as lockable adjacent to the stove and above the counter. It is unlocked at time of inspection due to staff distributing medications and preparing. Perishable and non-perishable food items are observed as in place in the refrigerator in the kitchen. Additional refrigerators are observed and contain additional food items in the garage area. Resident medications are in place and current. The first aid kit is maintained and is complete with required items as observed in an emergency back pack.

Continued on LIC809C...
SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8865
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:
DATE: 04/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/24/2024
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: SENIORS WITH GRACE CARE HOME
FACILITY NUMBER: 415201955
VISIT DATE: 04/24/2024
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Page 2 - LIC809

LPA observed fire alarm pulls throughout the facility, 3 fire extinguishers are observed with inspection dates of 09/19/2023, smoke detector/carbon monoxide detectors are in place through out resident rooms and main hallway, and central heating in the facility as in place. PPE supply is in place. Laundry room is also observed and is full operational and located near the kitchen area near a resident room. linen closet is observed as in place and per the licensee/administrator the residents also have extra linens in their rooms. Emergency exit routes are observed inside and outside to be free and clear of obstructions. Resident rooms were observed and all contained the required furniture as outlined in regulations. Water temperature is tested at 105F in common bathroom near the living room where a large shower is in place and shower chair for resident use. Bathroom is clean and operational.

The facility does not handle resident money. Administrator certificate for Grace Manuel is observed as current expiring 10/16/2024. Back up administrator certificate is observed for Noel Manuel as expiring 10/16/2024. LPA reviewed associations with the licensee and she says it is current to who is present on this day but will disassociate those who are no longer working at the facility. 2 of 6 resident files are reviewed and are current. 3 staff files are reviewed and are current. Staff training is on file and current.

The following updated forms are being requested to be received by 05/01/2024:

• LIC610E Emergency Disaster Plan
• LIC 308 Designation of Administrative Responsibility
• LIC 500 Personnel Report
• Updated administrator certificate
• LIC9020 Client Roster
• Certificate of Liability Insurance
• Control of property

Per the California Code of Regulations, Title 22, Division 6, Chapter 6, there are no deficiencies cited on this day. Report is reviewed with licensee/administrator Grace Manuel.
SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8865
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:

DATE: 04/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2