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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415202040
Report Date: 05/10/2018
Date Signed: 10/12/2021 10:38:06 AM

Document Has Been Signed on 10/12/2021 10:38 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
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:ST. CLOUD HOMEFACILITY NUMBER:
415202040
ADMINISTRATOR:ERNESTO PEREZFACILITY TYPE:
734
ADDRESS:2990 ST. CLOUD DR.TELEPHONE:
(650) 952-7778
CITY:SAN BRUNOSTATE: CAZIP CODE:
94066
CAPACITY: 4CENSUS: 4DATE:
05/10/2018
TYPE OF VISIT:Annual/RequiredUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Lyn Calamucha and Joan Gumatay and Tina DesuasidoTIME COMPLETED:
06:15 PM
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[2]LPA Audrey Jeung toured facility and grounds. All passageways are unobstructed and there are no accessible bodies of water or safety hazards observed. Toilet and bathing facilities are maintained in sanitary operational condition. Lighting is sufficient throughout the home and carbon monoxide detector is operational. Medications, toxins and sharps are stored appropriately and inaccessible to clients. Hot water temperature is tested in main shower/bathroom.at 115 degrees. Food supply--consisting of canned liquid formula for all residents--and first-aid kit are inspected. Disaster drills are documented; the most recent one was done in March 2018. Facility RNs and LVNs administer medications, feeding and hydration to the clients through their gastrostomy tubes. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed. Cristina Desuasido is a certified ARF administrator(x6/18) that oversees facility operations.

The following forms are available at www.ccld.ca.gov are to be completed and submitted to CCL by 5/24/18:



• LIC 309 Administrative Organization
• LIC 500 Personnel Report
• LIC 308 Designation of Administrative Responsibility
• LIC 400 Afidavit Regarding Client Cash Resources
• LIC 610 Emergency Disaster Plan
SUPERVISORS NAME: Vivien Helbling
LICENSING EVALUATOR NAME: Julio Montes
LICENSING EVALUATOR SIGNATURE: DATE: 05/10/2018
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/10/2018
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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Document Has Been Signed on 10/12/2021 10:37 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 10/12/2021 10:30 AM


Citations on this Visit Report are Under Appeal!


Created By: Julio Montes On 05/10/2018 at 04:47 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: ST. CLOUD HOME
FACILITY NUMBER: 415202040

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/10/2018
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Under Appeal
Type A
05/11/2018
Section Cited
CCR
80019(e)(1)

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citation and civil penalty appealed - appeal granted citation and civil penalty dismissed
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Vivien Helbling
LICENSING EVALUATOR NAME:Julio Montes
LICENSING EVALUATOR SIGNATURE:
DATE: 05/10/2018
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2018


LIC809 (FAS) - (06/04)
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