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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600122
Report Date: 03/21/2024
Date Signed: 03/25/2024 08:13:41 AM

Document Has Been Signed on 03/25/2024 08:13 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: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: 6DATE:
03/21/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Administrator, Phil SurdelTIME COMPLETED:
01:00 PM
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On March 21, 2024, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced annual visit. LPA met with Administrator, Phil Surdel and House Manager, Flordilita Silva and explained the purpose of the visit.

LPA toured the facility inside and outside including but not limited to; resident rooms, communal bathroom, common areas & kitchen. The indoor and outdoor passageways were free of obstruction. No accessible bodies of water of fire safety hazards observed. There are four resident bedrooms; two of which are private and two are shared. Two full bathrooms were observed to be clean and equipped with liquid soap and paper towels. LPA toured dining room and kitchen. LPA observed 2 days perishables and 7 days non-perishables. Washer and dryer were observed to be in good repair. No clients were observed during the visit. According to the Program Director, the clients were at their day programs. Extra linen was present and first aid kit was observed to be complete.

Chemicals, medications, and sharps were locked and inaccessible to residents. Hot water temperature throughout the facility was 110 degrees F. Overall the facility maintained a comfortable temperature and lighting is sufficient for comfort. Carbon monoxide monitors are working properly. All fire extinguishers have been checked and current as of April 2023. Emergency drills are logged and done every three months.

LPA reviewed 5 client records and 5 staff records. Client records are updated, complete and signed. Staff records are complete, with training logs that have met the basic requirement. Medication review was done, and all medications are accounted for, and centrally stored medication records are updated.

No citations are issued during the visit. Report is reviewed with the administrator and a copy is provided.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE: DATE: 03/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/06/2024
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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