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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600658
Report Date: 08/20/2024
Date Signed: 08/20/2024 02:23:16 PM

Document Has Been Signed on 08/20/2024 02:23 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:DAMENIK'S HOMEFACILITY NUMBER:
415600658
ADMINISTRATOR/
DIRECTOR:		MONTILLA, DANILO F.FACILITY TYPE:
740
ADDRESS:851 BADEN AVENUETELEPHONE:
(650) 827-1100
CITY:SOUTH SAN FRANCISCOSTATE: CAZIP CODE:
94080
CAPACITY: 15CENSUS: 15DATE:
08/20/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:50 PM
MET WITH:Matt Montilla & Nikki MontillaTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
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On 8/20/2024, Licensing Program Analyst (LPA) Grace Donato conducted a case management visit concerning an incident report received. LPA met with Assistant Administrators Matt Montilla & Nikki Montilla. LPA explained the purpose of today's visit.

LPA visited due to the incident report received from the Ombudsman regarding a resident (R1) having fell twice in a span of 2 days, 8/14 & 8/16/2024, between 3am-5am. Both times are when the NOC shift staff is working on another resident. R1 has neuro-cognitive disorder and wandering tendencies. A floor alarm has been placed on 7/30/2024, R1 also has a body alarm. Facility has followed protocol regarding reporting requirements and what to do in cases of fall in the facility.

The severity of the wandering behavior was not disclosed during pre appraisal.

As of this report, facility has tried to follow up with the hospital regarding R1s well being but is not able to get any information.

No citations issued today. Report is reviewed and copy is provided.
SUPERVISORS NAME: Andrea Medlin
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE: DATE: 08/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/20/2024
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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