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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600122
Report Date: 06/21/2022
Date Signed: 06/21/2022 03:14:21 PM

Document Has Been Signed on 06/21/2022 03:14 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
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:FHAR-HILLER STREET HOMEFACILITY NUMBER:
415600122
ADMINISTRATOR:PHIL SURDELFACILITY TYPE:
735
ADDRESS:803 HILLER STREETTELEPHONE:
(650) 508-0212
CITY:BELMONTSTATE: CAZIP CODE:
94002
CAPACITY: 6CENSUS: 5DATE:
06/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Administrator, Phil SurdelTIME COMPLETED:
03:30 PM
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On June 21, 2022, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced infection control inspection. Upon arrival, LPA observed the COVID-19 signage posted at that front door. LPA met with facility manager, Coryse Ngangmenyi and Administrator, Phil Surdel joined shortly thereafter. LPA was screened at entry point and the manager was able to provide screening log documentation for residents, staff, and visitors.

LPA toured facility and grounds. No accessible bodies of water or fire safety hazards observed. This is a single story facility with 4 bedrooms; 2 private rooms and 2 shared rooms. LPA observed the 2 shared rooms with beds 6ft apart. LPA observed the tqo bathrooms to be in good repair and odor free. According to the Administrator, liquid soap and paper towels are not in the bathrooms because resident's are unable to maintain it because of their behaviors. LPA toured the kitchen and advised Administrator to not keep any hand-towels and to ensure all trash cans have lids.

LPA observed 2 day perishable and 7 day non-perishable. LPA observed the 30-day PPE supply. Medications, toxins and sharps are stored appropriately and inaccessible to residents, and a comfortable temperature is maintained, lighting is sufficient for comfort. First aid kit was observed to be completed. Extra linen was observed to be present. Washer and dryer was observed to be in good working condition.

LPA requests for the following to be sent to CCLD by 6/28/22:
  • LIC308 Designation of Administrative Organization
  • LIC500 Personnel Report
  • Administrator Certificate
  • LIC610D Emergency Disaster Plan


Report is reviewed with Administrator, and a copy is provided.
SUPERVISORS NAME: Julio Montes
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE: DATE: 06/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/21/2022
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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