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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415202046
Report Date: 01/29/2024
Date Signed: 02/01/2024 11:49:17 AM

Document Has Been Signed on 02/01/2024 11:49 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
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: 3DATE:
01/29/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Anna Fernandez and Claire AscalonTIME COMPLETED:
12:45 PM
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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 113 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. Two residents are dependent upon G-tube feeding for nutrition and hydration, and at least 7-day supply of formula is maintained. 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 12/2023. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been verified. Facility employs LVNs and RNs; their licenses are checked and valid. Madonna Valencia and Claire Ascalon are certified ARF administrators (x 10/25 and 6/24) that oversee 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 information is given to LPA today:

- Proof of current surety bonding


No deficiencies of the CA Code of REgulations, Title 22, are observed today. See Advisory Notes issued--2 pages.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Audrey Jeung
LICENSING EVALUATOR SIGNATURE: DATE: 01/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/29/2024
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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