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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600693
Report Date: 10/08/2023
Date Signed: 10/08/2023 06:36:37 PM


Document Has Been Signed on 10/08/2023 06:36 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:AM RESIDENTIAL CARE HOMEFACILITY NUMBER:
415600693
ADMINISTRATOR:DELA CRUZ, ANA/MONEL, DANFACILITY TYPE:
740
ADDRESS:1000 BALBOA AVENUETELEPHONE:
(650) 348-8212
CITY:BURLINGAMESTATE: CAZIP CODE:
94010
CAPACITY:6CENSUS: 5DATE:
10/08/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Anicia Dela CruzTIME COMPLETED:
07:00 PM
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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to conduct a Required - 1 Year visit on 10/8/23 at 4:00PM. LPA met with Anicia Dela Cruz, Administrator and Rosita Padolina, Caregiver and stated the purpose of the visit. The Administrator Certificate was observed for Anicia Dela Cruz which expires 11/7/23.

The facility is licensed for a capacity of 6 non-ambulatory residents of which 3 may receive hospice care services. There are 3 residents receiving hospice services at this time. LPA observed residents and conversed with them during this visit.
LPA toured and inspected the physical plant inside and outside to ensure there are no safety hazards to residents. LPA observed 2-day perishables and 7-day non-perishables. The temperature inside the facility was observed to be at 78**F which is within the required range of 68-85*F. The hot water temperature was measured at 105.6 *F which is within the required range of 105-120*F. The most recent emergency drill was conducted 1/10/23. LPA observed a pull alarm system, fire extinguisher(s), smoke and carbon monoxide detectors in the facility. LPA observed the centrally stored medications area to be locked and inaccessible to residents. The first aid kit contained the required items such as sterile dressings, bandages, adhesive tape, scissors, tweezers, thermometers, antiseptic solution and guide.

LPA observed 2 staff and 2 resident files and conducted interviews during this visit.

Upon a file review the following items were discussed to be submitted with any changes annually:
Any addendums to the Infection Control Plan, Designation of Facility Responsibility (LIC308), Personnel Report (LIC500) to include the Administrator presence in the facility, Administrator Certificate-Updated, Emergency Disaster Plan (LIC610E), Liability Insurance, Health Screening with TB for all staff.

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies are being cited. An exit interview was conducted, a copy of the report was given.
SUPERVISOR'S NAME: Victoria BrownTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Victoria BrownTELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:
DATE: 10/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/08/2023
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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