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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600288
Report Date: 09/13/2024
Date Signed: 09/13/2024 01:36:08 PM

Document Has Been Signed on 09/13/2024 01:36 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:ROSENER HOUSE ADULT DAY SERVICEFACILITY NUMBER:
415600288
ADMINISTRATOR/
DIRECTOR:		DAO DOFACILITY TYPE:
775
ADDRESS:500 ARBOR ROADTELEPHONE:
(650) 322-0126
CITY:MENLO PARKSTATE: CAZIP CODE:
94025
CAPACITY: 80CENSUS: 42DATE:
09/13/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:10 AM
MET WITH:Dao Do, Program DirectorTIME VISIT/
INSPECTION COMPLETED:
01:50 PM
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On September 13, 2024, Licensing Program Analysts (LPAs) Kiran Jain and Komal Charitra arrived at the facility at 09:15 AM to conduct the Annual 1-year required inspection. LPAs met with the Program Director, Dao Do, and Program Manager, Shanah Hawk, and explained the purpose of the visit.

LPAs toured the physical plant and observed it to be clean and odor-free at a comfortable temperature and adequate lighting. This single-story building has a main activities area, 4 activity classrooms for arts, physical therapy, computer lab, and music, a dining room, a kitchen, 2 gender specific restrooms, 3 private restrooms, and an outdoor patio area. The outdoor patio area was fully enclosed and is used for gardening plus other outdoor activities. There are 3 exterior doors at the facility and delayed egress devices on these doors were observed to be operational. No accessible bodies of water or fire safety/tripping hazards were observed.

LPAs observed toxins, cleaning supplies, and sharp objects were stored/locked properly and inaccessible to the clients. No cooking was observed at the facility. The Program Director specified that clients’ lunch is catered through the Meals on Wheels nutrition program and is brought to the facility in the morning. Staff warms the food in the kitchen area before serving the lunch. The Refrigerator in the kitchen is used to store clients’ lunch if they bring from home.

The bathrooms were observed to be clean and equipped with trash cans, grab bars, liquid soap, and paper towels. An emergency call system is installed in all the bathrooms, and signals/alarms from them are monitored at the reception desk. The bathroom faucet water temperature was measured at 116.4°F.

Participants were observed sitting in the main common area, engaged in activities, singing, and dancing. LPAs reviewed 5 random participant files and 5 random staff files. All were observed to be complete. The client’s medications were securely stored in a locked container/cabinet in the nurse’s room.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Kiran Jain
LICENSING EVALUATOR SIGNATURE: DATE: 09/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/13/2024
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
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: ROSENER HOUSE ADULT DAY SERVICE
FACILITY NUMBER: 415600288
VISIT DATE: 09/13/2024
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Fire extinguishers were fully charged and last serviced on March 2024. Smoke detectors and carbon monoxide detectors were observed to be in working condition. Emergency exit routes were observed. The First Aid kit was checked and observed to be complete. Emergency drills are conducted quarterly with the last drill documented on June 2024.

The following updated forms are requested to be submitted to CCLD by 09/20/2024:
· LIC 500: Personnel Report
· LIC 308: Designation of Facility Responsibility
· Facility Floor Plan
· Liability Insurance

No deficiencies were cited during today's visit.

An exit interview was conducted. This report was reviewed with Program Director, Dao Do and a copy of this report was left at the facility.

SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Kiran Jain
LICENSING EVALUATOR SIGNATURE:

DATE: 09/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2024
LIC809 (FAS) - (06/04)
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