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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600729
Report Date: 06/17/2024
Date Signed: 06/17/2024 05:41:33 PM


Document Has Been Signed on 06/17/2024 05:41 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:BEL AMOR IIIFACILITY NUMBER:
415600729
ADMINISTRATOR:DEANDA, OLIVIA & MANNYFACILITY TYPE:
740
ADDRESS:169 SAN FELIPE AVENUETELEPHONE:
(650) 871-7931
CITY:SOUTH SAN FRANCISCOSTATE: CAZIP CODE:
94080
CAPACITY:6CENSUS: 6DATE:
06/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:36 PM
MET WITH:Reyna EpsteinTIME COMPLETED:
06:00 PM
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On 6/17/2024, LPA Grace Donato made an unannounced annual visit to the facility. LPA met with Staff, Reyna Epstein. LPA explained the purpose of the visit.

LPA toured the facility inside and outside including all of resident rooms, common areas, kitchen area & garage. The indoor and outdoor passageways were free of obstruction. LPA observed a storage shed at the back of the house which was also checked. LPA observed some residents were in the living room watching tv. After a while, the residents were observed to be having coloring and reading activities. 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 106 deg F. The residents have adequate amount of linens and incontinence care items. All personal belongings are intact. Carbon monoxide monitors are working properly. All fire extinguishers have been checked and current. Resident bedrooms and bathrooms were observed to be in good repair equipped with grab bars and non-skid mats. LPA checked the food supply and there is adequate amount of food, 2 days for perishables and & 7 days non-perishable. Emergency drills are logged and done every quarter.

Six resident records and four staff records were reviewed. Resident records are updated, complete and signed. Staff records are complete, with training logs. Facility has a certified administrator, certificate still pending status. Medication review was done, and all medications are accounted for, and centrally stored medication records are updated.

LPA received updated Certificate of Liability Insurance and LIC500.

No deficiencies cited today. Report is reviewed and copy is provided.
SUPERVISOR'S NAME: Andrea MedlinTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Grace DonatoTELEPHONE: (714) 293-8294
LICENSING EVALUATOR SIGNATURE:
DATE: 06/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/17/2024
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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