<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600710
Report Date: 08/30/2024
Date Signed: 08/30/2024 03:15:45 PM


Document Has Been Signed on 08/30/2024 03:15 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:OIKOS CARE HOME, INC.FACILITY NUMBER:
415600710
ADMINISTRATOR:KOWK, YVONNE & LIU, KWAI KFACILITY TYPE:
740
ADDRESS:2311 TIPPERARY AVENUETELEPHONE:
(650) 244-9244
CITY:SOUTH SAN FRANCISCOSTATE: CAZIP CODE:
94080
CAPACITY:6CENSUS: 6DATE:
08/30/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:19 PM
MET WITH:Mirra RaxakoulTIME COMPLETED:
03:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 8/30/2024, LPA Grace Donato made an unannounced annual visit to the facility. LPA met with Assistant Administrator Mirra Raxakoul. LPA explained the purpose of the visit.

LPA toured the facility inside and outside including all of resident rooms, garage, and kitchen area. LPA observed a resident watching TV. Other residents are currently in Day Programs. LPA observed facility being deep cleaned upon arrival. 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 110 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. Food supply in kitchen and cabinets located in garage was observed with an adequate with two day perishable and seven day non-perishable food supply. Carbon monoxide/smoke detectors, and fire extinguisher were present throughout the facility. Facility has an updated log for emergency drill which is done every month.

Six resident records and five staff records were reviewed. Staff have criminal record and fingerprint clearances on file. Staff have current First Aid/CPR certifications on file. Resident records were reviewed and were observed to be complete. Medication review was done, and all medications are accounted for, and centrally stored medication records are updated.

LPA requested LIC 500 and Liability Insurance (once updated) to be emailed to LPA.

No deficiencies are cited at this time. Report is reviewed and a copy is provided.
SUPERVISOR'S NAME: Andrea MedlinTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Grace DonatoTELEPHONE: (714) 293-8294
LICENSING EVALUATOR SIGNATURE:
DATE: 08/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/30/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1