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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600158
Report Date: 05/23/2023
Date Signed: 05/23/2023 05:37:04 PM


Document Has Been Signed on 05/23/2023 05:37 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:OUR HOUSEFACILITY NUMBER:
415600158
ADMINISTRATOR:PAGADOR, LIONELFACILITY TYPE:
740
ADDRESS:1916 SHOREVIEW AVENUETELEPHONE:
(650) 401-7175
CITY:SAN MATEOSTATE: CAZIP CODE:
94401
CAPACITY:6CENSUS: 5DATE:
05/23/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Ludiben Balico, Lionel and Ursula PagadorTIME COMPLETED:
05:45 PM
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LPA Audrey Jeung toured facility and grounds, including, detached storage shed, which is locked. There are no accessible bodies of water or fire safety hazards observed. Medications, toxins and sharps are stored appropriately and inaccessible to clients, a comfortable temperature is maintained, and lighting is sufficient for comfort and safety. Toilet and bathing facilities are equipped with grab bars and nonskid flooring material. Hot water temperature is tested at 115 degrees in clients' bathroom. Food supply and first-aid kit are inspected. Client files are reviewed, and medications are recorded on Centrally Stored Medications Records, provided by pharmacy. An updated Disaster and Mass Casualty Plan is posted.

Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed, as well as staff training records. Lionel Pagador is a certified RCFE administrator (x12/23) that oversees facility operations.

The following forms are requested to be updated and returned to CCL by 6/6/23:
• LIC 500 Personnel Report
• LIC 308 Designation of Facility Responsibility
• LIC 999 Facility Sketch (including dimensions)
• LIC 9282 Infection Control Plan
Proof of current liability insurance

Personal Rights form (LIC613C-2) has been revised to include Health and Safety Code 1569.269, non-discrimination (LGBTQ) notice, AND Centralized Complaint and Information Bureau (CCIB) contact information. This information must be posted prominently in facility, and LIC613C-2 must be signed by resident or his/her representative.

No deficiencies of the RCFE California Code of Regulations, Title 22, Division 6, Chapter 8 are cited. See Advisory Notes for technical violations to be corrected--5 pages.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:
DATE: 05/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/23/2023
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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