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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600266
Report Date: 09/06/2024
Date Signed: 09/06/2024 04:14:42 PM


Document Has Been Signed on 09/06/2024 04:14 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:ENCINA CARE HOMEFACILITY NUMBER:
415600266
ADMINISTRATOR:PERMITO, MARIA ELENAFACILITY TYPE:
740
ADDRESS:354 ENCINA AVENUETELEPHONE:
(650) 364-1657
CITY:REDWOOD CITYSTATE: CAZIP CODE:
94061
CAPACITY:6CENSUS: 5DATE:
09/06/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Maria Permito, Licensee/AdministratorTIME COMPLETED:
04:15 PM
NARRATIVE
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On September 06, 2024, Licensing Program Analysts (LPAs) Kiran Jain and John Calandra arrived at the facility at 2:00 PM to conduct the Annual 1-year required inspection. LPAs met with Maria Permito, Licensee/Administrator and explained the purpose of the visit.

LPAs Jain and Calandra toured the physical plant. This is a single-story building with 9 bedrooms, 5 bathrooms, living room, and a kitchen with dining. No accessible bodies of water or hazards were observed. The fire extinguisher was fully charged and last serviced on August 2023. The smoke detector and carbon monoxide detector were fully operational.

All rooms were observed to be clean with sufficient furniture and lighting. The hot water temperature in the bathroom sink faucet was measured at 103.8°F. This is not within the required range of 105-120°F. In the presence of the LPAs, the licensee adjusted the hot water temperature to the required range. No expired food items were observed. The facility had the required 7 days of non-perishables and 2 days of perishables.

Sharp objects, detergents, poisons, and soap were observed to be accessible to persons in care. In the presence of the LPAs, they were locked and are no longer accessible to persons in care.

LPAs reviewed three resident records and three staff records. All were observed to be complete.

The following documents were requested and received by the LPAs:
· Fire and Safety Inspection Report
· Liability Insurance


LPAs will return at a later date to complete the Annual inspection.

No deficiencies were cited during today's visit.

An exit interview was conducted. This report was reviewed with Maria Permito, Licensee/Administrator and copy of this report was left at the facility.
SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Kiran JainTELEPHONE: 650-416-4836
LICENSING EVALUATOR SIGNATURE:
DATE: 09/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/06/2024
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


Document Has Been Signed on 09/06/2024 04:14 PM - It Cannot Be Edited

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: ENCINA CARE HOME
FACILITY NUMBER: 415600266

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(3)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (3) Taps delivering water at 125 degree F (52 degrees C) or above shall be prominently identified by warning signs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
Plan of Correction
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Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Kiran JainTELEPHONE: 650-416-4836
LICENSING EVALUATOR SIGNATURE:
DATE: 09/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/06/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2