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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600222
Report Date: 06/10/2024
Date Signed: 06/10/2024 04:11:58 PM


Document Has Been Signed on 06/10/2024 04:11 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:BAYVIEW VILLAFACILITY NUMBER:
415600222
ADMINISTRATOR:LONCAR, LJUBICA VIOLETFACILITY TYPE:
740
ADDRESS:777 BAYVIEW DRIVETELEPHONE:
(650) 596-3489
CITY:SAN CARLOSSTATE: CAZIP CODE:
94070
CAPACITY:47CENSUS: 15DATE:
06/10/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Designated Responsible Staff - Khin ThidaTIME COMPLETED:
03:45 PM
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On 06/10/2024, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced required - 1 year inspection visit. LPA met with designated responsible staff person Khin Thida and explained purpose of today's visit.

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 located on the lower level (Garden level) which is clean and observed appliances are in good repair. Knives are stored in the kitchen behind locked doors. The garden level/lower level is vacant so food is prepared and brought up to the dining room on the upper level. 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 04/11/2024, smoke detector/carbon monoxide detectors are observed in place through out the facility, and central heating/cooling system. Fire panel is observed as last serviced on 03/30/2023 which is located at the rear wall of the front reception desk. 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 vacant resident bathroom adjacent to the front desk area. 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 06/02/2024. Resident linen supplies are observed as in place on the second floor of the facility.

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SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8865
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
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: BAYVIEW VILLA
FACILITY NUMBER: 415600222
VISIT DATE: 06/10/2024
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All files are current per review made. P&I is not handled by the facility. Administrator certificate is observed as expired as of 01/20/2023 but still has not received the updated administrator certificate to this date. Documentation is observed that renewal was sent and paid for via check, and was cashed, on time but the certificate has not been received. Annual fees are discussed with Khin.

The following updated item is to be sent to the department by 06/17/2024:

• Copy of control of property such as lease agreement or deed

No citations issued. Report is reviewed with administrator. Copy is provided.
SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8865
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
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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