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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600085
Report Date: 10/07/2023
Date Signed: 10/07/2023 06:51:16 PM

Document Has Been Signed on 10/07/2023 06:51 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:ACACIA MANORFACILITY NUMBER:
415600085
ADMINISTRATOR:TAN, LUZVIMINDAFACILITY TYPE:
740
ADDRESS:1510 NEWLANDS AVENUETELEPHONE:
(650) 579-1915
CITY:BURLINGAMESTATE: CAZIP CODE:
94010
CAPACITY: 6CENSUS: 2DATE:
10/07/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
05:30 PM
MET WITH:Luzviminda TanTIME COMPLETED:
07:00 PM
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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to conduct a Required - 1 Year visit on 10/7/23 at 5:30PM. LPA met with Luzviminda Tan, Administrator and stated the purpose of the visit. The facility is licensed for a capacity of 6 non-ambulatory residents in rooms 2,3 and 4 of which 3 may receive hospice care services. There are 2 residents receiving hospice services at this time.

The Administrator Certificate was observed for Luzviminda Tan which expires 8/26/24.

LPA observed residents and conversed with them during this visit. LPA toured and inspected the physical plant inside and outside to ensure there are no safety hazards to residents. LPA observed 2-day perishables and 7-day non-perishables. The temperature inside the facility was observed to be at 78.1*F which is within the required range of 68-85*F. The hot water temperature was measured at 105 *F which is within the required range of 105-120*F. Facility has a tankless water heater. LPA observed fire extinguisher(s), smoke and carbon monoxide detectors in the facility. LPA observed the centrally stored medications area to be locked and inaccessible to residents.

The first aid kit contained the required items such as sterile dressings, bandages, adhesive tape, scissors, tweezers, thermometers, antiseptic solution and guide.

LPA observed 1 staff and 2 resident files and conducted interviews during this visit.

Upon a file review the following items were discussed to be submitted with any changes annually:
Any Addendums to the Infection Control Plan, Plan of Operation, Designation of Facility Responsibility (LIC308), Personnel Report (LIC500) to include the Administrator presence in the facility, Administrator Certificate-Updated, Emergency Disaster Plan (LIC610E), Plan of Operation, Plan for incidental and Medical and Dental Care, Health Screening with TB, Transportation Procedures, and Liability Insurance.

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies are being cited. An exit interview was conducted, a copy of the report was given.
SUPERVISORS NAME: Victoria Brown
LICENSING EVALUATOR NAME: Victoria Brown
LICENSING EVALUATOR SIGNATURE: DATE: 10/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/07/2023
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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