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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600085
Report Date: 05/30/2024
Date Signed: 05/30/2024 05:22:06 PM


Document Has Been Signed on 05/30/2024 05:22 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:ACACIA MANORFACILITY NUMBER:
415600085
ADMINISTRATOR:TAN, LUZVIMINDAFACILITY TYPE:
740
ADDRESS:1510 NEWLANDS AVENUETELEPHONE:
(650) 579-1915
CITY:BURLINGAMESTATE: CAZIP CODE:
94010
CAPACITY:6CENSUS: 1DATE:
05/30/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Caregiver, Evelyn BalagaTIME COMPLETED:
12:15 PM
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On May 30, 2024 Licensing Program Analyst (LPA) Murial Han conducted an unannounced annual inspection. LPA met with caregiver, Evelyn Balaga and explained the purpose of the visit. The administrator, Luzviminda Tan arrived shortly thereafter and assisted with the inspection.

LPA toured the facility inside and out and inspected the living room, dining area, kitchen, bedrooms, bathrooms, and backyard. The indoor and outdoor passageways were free of obstruction. The facility has 4 resident rooms and 4 bathrooms. Furniture and furnishings were observed to be sufficient. Food supplies were sufficient of 2- days perishables and 7- days of non-perishables. Toilet, hand washing and bathing areas were observed clean and in operating condition. Showers were observed equipped with non-skid mats and grab bars. Comfortable temperature is maintained and lighting is sufficient for comfort.

Central storage for medications, sharps and chemicals were observed to be locked and inaccessible to residents in care.

Hot water temperature in the kitchen and bathroom were measured at 107-110 degrees Fahrenheit. Fire extinguishers were checked and last inspected on 8/25/2022.

A review of (1) resident files was conducted and noted on the LIC 858.
A review of (1) staff files was conducted and noted on the LIC 859.

No deficiency is cited today.

This report is reviewed and discussed with the administrator; a copy is provided.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:
DATE: 05/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/30/2024
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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