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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600197
Report Date: 11/08/2023
Date Signed: 11/08/2023 01:38:33 PM


Document Has Been Signed on 11/08/2023 01:38 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066



FACILITY NAME:FRIENDLY ACRES ELDERLY HOMEFACILITY NUMBER:
415600197
ADMINISTRATOR:FRANCO, KALAITA TAVAKEFACILITY TYPE:
740
ADDRESS:3526 PAGE STREETTELEPHONE:
(650) 369-4503
CITY:REDWOOD CITYSTATE: CAZIP CODE:
94063
CAPACITY:6CENSUS: 3DATE:
11/08/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Caregiver Mike Alvis/Administrator Kalaita FrancoTIME COMPLETED:
01:45 PM
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On this day LPA Vado conducted an unannounced case management - deficiencies visit in order to observe and clear citations issued on a previous annual visited conducted on 10/14/2023. LPA Vado met with administrator Kalaita Franco then caregiver Mike Alvis. LPA explained the purpose of today's visit.

On this day the following citations were are not completed per observations and interviews conducted. Ongoing civil penalties are being issued on this day for each citation that has not been cleared. Civil penalties are ongoing until corrected.

"87412(a) - The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: "
Civil penalty assessed from 10/31/2023 through 11/08/2023 at $100 a day = $900 - Penalty is ongoing until corrected.

"87506(a) - The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff."
Civil penalty assessed from 10/31/2023 through 11/08/2023 at $100 a day = $900 - Penalty is ongoing until corrected.

"80075(f) - (f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross."
Civil penalty assessed from 10/24/2023 through 11/08/2023 at $100 a day = $1600 - Penalty is ongoing until corrected.

Continued on next page...
SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8865
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:
DATE: 11/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/08/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


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: FRIENDLY ACRES ELDERLY HOME
FACILITY NUMBER: 415600197
VISIT DATE: 11/08/2023
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Page 2 - LIC809 - Case Management Deficiencies

"87405(a) Administrator - Qualifications and Duties. All facilities shall have a qualified and currently certified administrator."
Civil penalty assessed from 10/17/2023 through 11/08/2023 at $100 a day = $2300 - Penalty is ongoing until corrected.

This report is reviewed with both Mike Alvis and the administrator Kalaita Franco. Copy of this report is provided on this day. Appeal rights are provided on this day.
SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8865
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:

DATE: 11/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2023
LIC809 (FAS) - (06/04)
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