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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600721
Report Date: 02/09/2024
Date Signed: 02/09/2024 07:22:23 PM


Document Has Been Signed on 02/09/2024 07:22 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:BOUGAINVILLEAS CARE HOMEFACILITY NUMBER:
415600721
ADMINISTRATOR:PENA, L. AND PINEDA, R.FACILITY TYPE:
740
ADDRESS:201 ALTA VISTA DRIVETELEPHONE:
(650) 737-0832
CITY:SOUTH SAN FRANCISCOSTATE: CAZIP CODE:
94080
CAPACITY:22CENSUS: 14DATE:
02/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:16 AM
MET WITH:Lily PenaTIME COMPLETED:
11:45 AM
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On 2/9/2024 LPA Grace Donato made an unannounced annual visit to the facility. LPA met with Administrator Lily Pena and care staff Hazel Romero. 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 all residents resting in their bedrooms and other residents are having an activity in the living room. While touring the facility it was observed that the room temperature was at 71 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 in the kitchen have a lock box accessible by code and toxic materials were observed locked. Food supply in kitchen was observed with an adequate two day perishable and seven day non-perishable. Carbon monoxide/ smoke detectors, sprinklers, and fire extinguisher were present throughout the facility.

Five 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 with documents such as Admission Agreements, Medical Assessments, and Needs and Service Plans.

Centrally stored medication was locked in the medicine cart and inaccessible by residents. All medication was labeled and sorted by resident name. All medication logs are complete and updated.

LPA requested the following: Control of Property and Certificate of Liability Insurance.

No deficienes being cited today. Report is reviewed and copy is provided.
SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8865
LICENSING EVALUATOR NAME: Grace DonatoTELEPHONE: (714) 293-8294
LICENSING EVALUATOR SIGNATURE:
DATE: 02/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/09/2024
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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