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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415202046
Report Date: 04/04/2023
Date Signed: 04/04/2023 01:34:19 PM

Document Has Been Signed on 04/04/2023 01:34 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
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:GORDON HOMEFACILITY NUMBER:
415202046
ADMINISTRATOR:MADONNA VALENCIAFACILITY TYPE:
734
ADDRESS:1415 GORDON ST.TELEPHONE:
(650) 365-3688
CITY:REDWOOD CITYSTATE: CAZIP CODE:
94061
CAPACITY: 5CENSUS: 4DATE:
04/04/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Anna Fernandez, Joshua Lee, Claire AscalonTIME COMPLETED:
01:45 PM
NARRATIVE
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LPA Audrey Jeung toured facility and grounds. There are no accessible bodies of water nor fire safety hazards observed. All passageways are accessible. A comfortable temperature is maintained and lighting is adequate for safety. Hot water temperature is tested at 115 degrees in client bath/shower room. Food supply--consisting of formula and solid food--and first-aid kit are inspected, and hygiene items for general use are maintained. Three residents are dependent upon G-tube feeding for nutrition and hydration, and facility employs LVNs and RNs; their licenses are checked and valid. Client files are reviewed and contain medical assessments. Medications are recorded on Centrally Stored Medications Records. Disaster drills are documented; the most recent was conducted 3/1/23. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been verified. Madonna Valencia is a certified ARF administrator (x 10/23) that oversees facility operations for this Adult Residential Facility for Persons with Special Health Care Needs. There is no staff room, as facility employs awake night staff.

The following forms are completed and given to LPA today:

• LIC 500 Personnel Report
• LIC 610 Emergency Disaster Plan
• LIC 308 Designation of Facility Responsibility
• LIC 309 Administrative Organization



Deficiency of the CA Code of REgulations, Title 22, is observed and cited on a following page.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Audrey Jeung
LICENSING EVALUATOR SIGNATURE: DATE: 04/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/04/2023
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 04/04/2023 01:34 PM - It Cannot Be Edited


Created By: Audrey Jeung On 04/04/2023 at 12:36 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
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: GORDON HOME
FACILITY NUMBER: 415202046

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/04/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above, as bleach, Comet cleanser, Windex, Pine Sol and other cleaning products are stored in laundry room and kitchen cabinets under the sinks, which are not locked.
This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/04/2023
Plan of Correction
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Under sink cabinets in laundry room and kitchen are locked in LPA's presence.
Deficiency corrected and cleared.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Cara Smith
LICENSING EVALUATOR NAME:Audrey Jeung
LICENSING EVALUATOR SIGNATURE:
DATE: 04/04/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/04/2023


LIC809 (FAS) - (06/04)
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