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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600425
Report Date: 08/13/2024
Date Signed: 08/13/2024 04:35:29 PM


Document Has Been Signed on 08/13/2024 04:35 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:C & C CAREHOMEFACILITY NUMBER:
415600425
ADMINISTRATOR:ETHEL AZCUETA-GUMBANFACILITY TYPE:
740
ADDRESS:2700 OAKMONT DRIVETELEPHONE:
(650) 583-3496
CITY:SAN BRUNOSTATE: CAZIP CODE:
94066
CAPACITY:6CENSUS: 5DATE:
08/13/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Caregiver, Cesar MedinaTIME COMPLETED:
10:30 AM
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On August 13, 2024 Licensing Program Analyst (LPA) Murial Han conducted an unannounced annual inspection. Upon arrival, LPA was greeted by caregiver, Cesar Medina and LPA explained the purpose of today's visit. The Administrator, Ethel Gumban arrival shortly thereafter and assisted with the inspection.

LPAs toured the facility and grounds. No accessible bodies of water or fire safety hazards observed. This is a single story home with 4 resident rooms, 2 full baths, one a half bath, and 1 staff room. LPA observed 2 shared resident rooms. LPA observed the other 2 resident rooms to be private. LPA observed all bathrooms to be clean and odor free.

LPA toured the living and dining room and observed it to be clean and clear from any tripping hazards. A comfortable temperate is maintained. Lighting was sufficient for comfort. Extra linen was observed to be present. LPA toured the kitchen and observed medication, sharps, and chemicals to be locked and stored appropriately and inaccessible to residents. LPA toured the kitchen and observed 2 day perishable and 7 day non-perishable.

LPA toured the garage where the washer and dryer were observed to be in good working condition.

Hot water temperature in the kitchen and bathroom were measured at 112-114 degrees Fahrenheit. Fire extinguishers were checked and last inspected on 4/9/2024. Disaster drills were reviewed.

A review of (5) resident files was conducted and noted on the LIC 858.
A review of (2) staff files was conducted and noted on the LIC 859.

No deficiency is cited today.

LPA reviewed report with Administrator and a copy is provided
SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:
DATE: 08/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/13/2024
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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