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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415202046
Report Date: 01/27/2025
Date Signed: 01/27/2025 01:09:21 PM

Document Has Been Signed on 01/27/2025 01:09 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:GORDON HOMEFACILITY NUMBER:
415202046
ADMINISTRATOR/
DIRECTOR:		MADONNA VALENCIAFACILITY TYPE:
734
ADDRESS:1415 GORDON ST.TELEPHONE:
(650) 365-3688
CITY:REDWOOD CITYSTATE: CAZIP CODE:
94061
CAPACITY: 5CENSUS: 4DATE:
01/27/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:15 AM
MET WITH:Anna Fernandez and Madonna ValenciaTIME VISIT/
INSPECTION COMPLETED:
01:15 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 117 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 at least 7-day supply of formula is maintained. Client files are reviewed and complete. Medications are recorded on Centrally Stored Medications Records. Disaster drills are documented; the most recent was conducted 12/2024. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been verified, and staff records are reviewed. Facility employs LVNs and RNs; their licenses are checked and valid. Direct care providers have current first aid training. Madonna Valencia is a certified ARF administrator (x 10/25) 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 information is given to LPA today:

- Administrative Organization (LIC309)
- Designation of Administrative Responsibility (LIC308)
- Emergency Disaster Plan (LIC610D)

Current FACILITY SKETCH is requested to be sent to CCLD BY 2/3/25


No deficiencies of the CA Code of REgulations, Title 22, are observed today.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Audrey Jeung
LICENSING EVALUATOR SIGNATURE: DATE: 01/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/27/2025
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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