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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600595
Report Date: 10/23/2023
Date Signed: 10/23/2023 03:09:14 PM


Document Has Been Signed on 10/23/2023 03:09 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
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066



FACILITY NAME:ALHAMBRA HOME CAREFACILITY NUMBER:
415600595
ADMINISTRATOR:FEDERICO MIRANDAFACILITY TYPE:
740
ADDRESS:498 ALHAMBRA ROADTELEPHONE:
(650) 589-1900
CITY:SOUTH SAN FRANCISCOSTATE: CAZIP CODE:
94080
CAPACITY:6CENSUS: 4DATE:
10/23/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:16 PM
MET WITH:Lyn Benedicto, CaregiverTIME COMPLETED:
03:20 PM
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On 10/23/23 Licensing Program Analysts (LPAs) Grace Donato & John Calandra made an unannounced annual visit to the facility. LPAs met with caregivers Lyn Benedicto and Teresita Elca. LPAs explained the purpose of the visit.

LPA toured the facility inside and outside including all of resident rooms, garage, and kitchen area. Three residents just arrived from Day Program, and are currently watching TV in the living room. While touring the facility it was observed that the room temperature was at 70 deg F. Hot water was also tested in the bathrooms and the temperature was 115 deg F. The facility is observed to be clean, odorless, and well maintained. Residents bedrooms were observed to be well organized and fully furnished with adequate lighting. Sharps and toxic materials were observed locked in the kitchen cabinet and underneath the sink and inaccessible to residents. Food supply in kitchen and bin located in garage was observed with an adequate two day perishable and seven day non-perishable food supply. Carbon monoxide/ smoke detectors, and fire extinguisher were present throughout the facility.

Two resident records and two staff records were reviewed. Resident’s PNI money was counted and all accounted for with proper log and receipts. Staff records are complete, with training logs. Medication review was done, and all medications are accounted for, and centrally stored medication records are updated.

No deficiencies are cited at this time. Report is reviewed and a copy is provided.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Grace DonatoTELEPHONE: (714) 293-8294
LICENSING EVALUATOR SIGNATURE:
DATE: 10/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/23/2023
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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