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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600736
Report Date: 08/02/2024
Date Signed: 08/02/2024 11:40:34 AM


Document Has Been Signed on 08/02/2024 11:40 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:ARAVILLE RESIDENTIAL CARE HOME IIIFACILITY NUMBER:
415600736
ADMINISTRATOR:PANIZA, DORIEFACILITY TYPE:
740
ADDRESS:106 SYCAMORE AVENUETELEPHONE:
(650) 871-8775
CITY:SOUTH SAN FRANCISCOSTATE: CAZIP CODE:
94080
CAPACITY:6CENSUS: 6DATE:
08/02/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Dorie PanizaTIME COMPLETED:
12:00 PM
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On 6/17/2024, LPAs Grace Donato & Kiran Jain made an unannounced annual visit to the facility. LPA met with Licensee/Administrator Dorie Paniza. LPA explained the purpose of the visit.

LPAs 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. LPAs observed some residents were in the living room watching tv and others were having breakfast. 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 residents have adequate amount of linens and incontinence care items. All personal belongings are intact. Carbon monoxide monitor is 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 five 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 Administrator Certificate. LPA requested the following documents to be emailed, Control of Property & 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: 08/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/02/2024
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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