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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600704
Report Date: 08/19/2026
Date Signed: 08/21/2026 10:31:44 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 08/21/2026 10:31 AM - 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:ENCHANTED GARDEN FOR SENIORSFACILITY NUMBER:
415600704
ADMINISTRATOR/
DIRECTOR:		GIUSTO, FERLENEFACILITY TYPE:
740
ADDRESS:188 STARLITE DRIVETELEPHONE:
(650) 212-2674
CITY:SAN MATEOSTATE: CAZIP CODE:
94402
CAPACITY: 6CENSUS: 5DATE:
08/19/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Assistant Administrator - Lolita FactolerinTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
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On 07/29/2025, Licensing Program Analyst (LPA) Vado Jaime Vado conducted an unannounced annual required inspection visit. LPA met with Assistant Administrator Lolita Factolerin and explained the purpose of today's visit. There are currently 5 residents in the facility and 4 staff present.

This is a single level facility, licensed for residents age range of 60 years and over all of which may be non-ambulatory. Hospice waiver on file. There is one hospice resident at this time. The physical plant was toured inside and outside of the facility to ensure the safety of the clients. LPA observed the facility kitchen which is clean and observed appliances that are in good repair. Knives are stored and locked in a kitchen drawer adjacent to the sink. Medications are locked in a cabinet adjacent to a double door that leads to the exterior patio. Perishable and non-perishable food items are observed as in place. Main kitchen has refrigerator which is functioning is observed with fresh food supplies in place. There are is one additional refrigerator in the garage for additional facility food supplies. Non-perishable food/emergency food supplies are in place. First aid kit is observed as complete with required items stored in a hallway cabinet. LPA observed that there are 3 fire extinguishers in place inspected on 06/09/2026, smoke detector, carbon monoxide detectors are observed in place through out the facility, and central HVAC. Fire pull stations are located in the main hallway at both ends of the hallway. Laundry area is observed as fully operational, and lockable, in the garage of the facility.


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April Cowan
Jaime Vado
DATE: 08/19/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/19/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: ENCHANTED GARDEN FOR SENIORS
FACILITY NUMBER: 415600704
VISIT DATE: 08/19/2026
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Emergency exit routes are observed inside and outside to be free and clear of obstructions. Last emergency/disaster drill was conducted on 08/02/2026 per file review. Water temperature is measured at 109F. Cleaning supplies are observed to be locked beneath the kitchen sink and additional toxins and cleaning supplies are observed to be locked in additional cabinets. This facility does not have fire sprinklers on site. LPA observed all resident rooms and all are observed as clean, free of odors, and contained all the required furniture per regulatory recommendations. There is one staff room in the facility accessible by a door in the common hallway and through the dining room area. Resident linen supplies are observed as in place stored in a hallway cabinet. There is one common full bathroom located at the end of the common hallway central to resident rooms. Shower floor does have non-skid surfacing but a non-skid mat is present for use. During today's inspection LPA reviewed 5 resident files and 6 staff files during today's inspection. 2 of 6 staff files did not have current CPR/First Aid training. Training hours are on file for staff dated in 2026. 1 of 5 resident files did not have current LIC602 or evidence of medical appraisal since 2025. Medications are inspected and are accurate to what is listed on centrally stored medication and destruction record. Administrator certificate is current expiring on 07/28/2027.

The following updated forms are requested to be submitted to CCLD by 08/26/2025:
• Copy of updated administrator certificate
• Copy of facility's liability insurance
• LIC500 Staff Schedule
• Copy of control of property

No citations issued on this day.

Report is reviewed with administrator assistant Lolita Factolerin and a copy is provided on this day.
NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: Jaime Vado
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/19/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/21/2026 10:31 AM - It Cannot Be Edited


Created By: Jaime Vado On 08/19/2026 at 12:08 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: ENCHANTED GARDEN FOR SENIORS
FACILITY NUMBER: 415600704

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/19/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/26/2026
Section Cited
CCR
87463(a)

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REAPPRAISALS
The pre-admission appraisa... shall be updated in writing as frequently as necessary or once every 12 months...to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. This regulation has not been met as evidenced by:
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Reappraisals shall be completed for R5, in the form of a physicians visit or updated LIC602, to maintain complaince with this regulation copies will be sent to the Department by due date stated.
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Based on resident file reviews, R5 diagnosed with dementia, is dated more than 12 months ago. Facility failed to ensure that appraisals are completed annually, which poses a potential health, safety or personal rights risk to clients in care.
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Type B
08/26/2026
Section Cited
CCR87411(c)(1)

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PERSONNEL REQUIREMENTS
Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement has not been met as evidenced by:
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First aid training for staff #1 and #6 shall be completed, to maintain complaince with this regulation, copies will be sent to the Department by due date stated.
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Based on staff files reviewed, 2 out of 6 staff first aid cards are not current, both expiring in January 2026 Licensee failed to ensure that staff who
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
April Cowan
NAME OF LICENSING PROGRAM MANAGER:
Jaime Vado
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/19/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/19/2026


LIC809 (FAS) - (06/04)
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