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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600191
Report Date: 06/23/2021
Date Signed: 06/23/2021 05:21:31 PM

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:ATRIA DALY CITYFACILITY NUMBER:
415600191
ADMINISTRATOR:JENNIFER DUENASFACILITY TYPE:
740
ADDRESS:501 KING DRTELEPHONE:
(650) 878-5111
CITY:DALY CITYSTATE: CAZIP CODE:
94015
CAPACITY:120CENSUS: 69DATE:
06/23/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Jennifer DuenasTIME COMPLETED:
04:00 PM
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On June 23, 2021 Licensing Program Analyst (LPA) Chris Hopkins conducted an unannounced annual required inspection. LPA met with Executive Director, Jennifer Duenas, and stated the purpose of the visit.

LPA toured the indoor and outdoor premises of the facility. The indoor and outdoor passageways were free of obstruction. LPA observed the six (6) resident bedrooms and bathrooms (Room 109, 125, 131, 202, 211, and 231), bedrooms were observed to be well organized and fully furnished with adequate lighting. Bathrooms are equipped with non-skid mats and grab bars. Bathrooms are sanitary and odorless. The hot water temperature was measured in residents bathrooms. The temperatures went as follows: Room 109, 118 degrees Fahrenheit, Room 125, 116 degrees Fahrenheit, Room 131, 114 degrees Fahrenheit, Room 202, 115 degrees Fahrenheit, Room 211 (Resident was using the bathroom), Room 231, 116 degrees Fahrenheit. The facility is observed to be clean, odorless, and well maintained. Food supply in kitchen was observed with an adequate two day perishable and seven day non-perishable food supply. Carbon monoxide, smoke detectors, and fire extinguisher were present at the facility. Centrally stored medication was locked in the Medical supply room and inaccessible by residents. All medication was labeled and sorted by resident name. Personal Protective Equipment (PPE) is adequate.

Staff records were reviewed. Staff have criminal record and fingerprint clearances on file. Staff have current First Aid/CPR certifications on file. Resident records were reviewed and were observed to be complete with documents such as Admission Agreements, Medical Assessments, and Needs and Service Plans.

No deficiencies observed today. Facility is operating in compliance with Title 22 regulations. This report was discussed with Executive Director, Jennifer Duenas, and a copy of this report was provided via email.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Christopher Hopkins-ClarkeTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2021
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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