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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600182
Report Date: 06/10/2024
Date Signed: 06/10/2024 11:56:17 AM

Document Has Been Signed on 06/10/2024 11:56 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:HAWTHORNE HOUSEFACILITY NUMBER:
415600182
ADMINISTRATOR/
DIRECTOR:
CARRIE RAMLOW, MSW, PDFACILITY TYPE:
772
ADDRESS:251 JACKSON AVENUETELEPHONE:
(650) 368-2383
CITY:REDWOOD CITYSTATE: CAZIP CODE:
94062
CAPACITY: 12CENSUS: 10DATE:
06/10/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Administrator - Sayoko YoshimuraTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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On 06/10/2024, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced infection control annual inspection. LPA met with administrator Sayoko Yoshimura and explained purpose of today's inspection.

LPA was allowed entry into the facility. This is a two level facility. Annual Fees are current. The physical plant was toured inside and outside to ensure the safety of the residents. LPA observed the facility kitchen which is clean and observed appliances are in good repair. Knives are stored in a counselors office adjacent to the kitchen. Perishable and non-perishable food items are observed as in place. There are multiple refrigerators and freezers in the garage areas which also carry additional food supplies. LPA observed the medications as in place and locked in a storage cabinet in a locked staff area behind locked doors. There are multiple first aid kits observed as complete with required items through out the facility. LPA observed that the facility is equipped with full sprinkler system, fire extinguishers are placed through out the facility last inspected on 06/10/2023, smoke detector/carbon monoxide detectors are observed in place through out the facility, and central heating/cooling system. Facility is also equipped with fire pull alarms through out the facility. PPE and additional food supplies are observed as in place. Laundry area is also observed as fully operational located in the garage area. Emergency exit routes are observed inside and outside to be free and clear of obstructions. Water temperature was measured at 110F in a resident bathroom adjacent to room 3. Facility maintains a water temperature log as well which is also reviewed. LPA observed two resident rooms at random and both rooms appeared clean, free of odors, and contained all the required furniture per regulatory recommendations. Multiple resident bathrooms are observed as clean and in good working condition. Non-skid flooring is in place in showers and tubs. Disaster drills take place monthly per records observed. Last taking place on 03/17/2024. Resident linen supplies are observed as in place on the second floor of the facility.

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SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Jaime Vado
LICENSING EVALUATOR SIGNATURE: DATE: 06/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/10/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: HAWTHORNE HOUSE
FACILITY NUMBER: 415600182
VISIT DATE: 06/10/2024
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LPA reviewed 3 resident files and also reviewed 4 staff files on this day. All files are current per review made. P&I is not handled by the facility. Administrator certificate is observed as current expiring on 01/08/2025..

The following updated forms are requested to be submitted to CCLD by 06/17/2024:

• Copy of updated Administrator Certificate
• Updated surety bond with expiration date
• LIC 308 Designation of Administrative Responsibility
• LIC400 Affidavit Regarding Client/Resident Cash Resources
• LIC610D Emergency Disaster Plan
• LIC500 Staff Schedule
• Copy of control of property such as lease agreement or deed

No citations issued. Report is reviewed with administrator. Copy is provided.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Jaime Vado
LICENSING EVALUATOR SIGNATURE:

DATE: 06/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2024
LIC809 (FAS) - (06/04)
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