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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600751
Report Date: 07/24/2024
Date Signed: 07/24/2024 05:50:40 PM

Document Has Been Signed on 07/24/2024 05:50 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:HOME AT CRESTMOORFACILITY NUMBER:
415600751
ADMINISTRATOR/
DIRECTOR:
PRADO, IMELDAFACILITY TYPE:
740
ADDRESS:2600 PLYMOUTH WAYTELEPHONE:
(650) 872-8419
CITY:SAN BRUNOSTATE: CAZIP CODE:
94066
CAPACITY: 6CENSUS: 4DATE:
07/24/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH:Caregiver, Krisanta MercadoTIME VISIT/
INSPECTION COMPLETED:
12:20 PM
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On July 24, 2024, Licensing Program Analyst(LPA) Murial Han conducted an unannounced annual inspection. LPA was greeted by caregivers, Krisanta Mercado and Dinah Elsa Habla and explained the purpose of today's visit. Administrator, Imelda Prado arrived shortly thereafter and assisted with the inspection.

LPA toured facility and grounds. No accessible bodies of water or fire safety hazards observed. LPA toured the facility inside and outside including all of resident rooms, common areas, and kitchen area. The indoor and outdoor passageways were free of obstruction. Facility was overall clean and odor-free. Comfortable temperature is maintained and lighting is sufficient for comfort.

LPA observed 1 private resident room, 2 shared rooms and 1 staff room. The rooms were spacious and included all required furnishings. Two full bathrooms were observed to be clean and in operating condition. Hot water temperature was measured at 105- 112 F. Fire extinguishers were inspection on 1/11/2024.

LPA observed medications, toxins and sharps to be locked and inaccessible to residents in care. 2 days for perishables and & 7 days non-perishable were observed to be present.

Emergency drill records were reviewed.

A review of (4) resident files was conducted and noted on the LIC 858.
A review of (2) staff files was conducted and noted on the LIC 859.

No deficiency cited today.

This report is reviewed and discussed with the administrator. A copy is provided.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE: DATE: 07/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/24/2024
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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