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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600769
Report Date: 03/08/2021
Date Signed: 03/08/2021 05:48:01 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:LYONS ELDERLY HOME LLCFACILITY NUMBER:
415600769
ADMINISTRATOR:JAVIER, JOSEPHINEFACILITY TYPE:
740
ADDRESS:1168 LYONS STREETTELEPHONE:
(650) 556-1754
CITY:REDWOOD CITYSTATE: CAZIP CODE:
94061
CAPACITY:6CENSUS: 3DATE:
03/08/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Jospehine JavierTIME COMPLETED:
12:30 PM
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On this day at 1200, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced case management tele-inspection regarding and incident that occurred. LPA met with licensee Josephine Javier and explained the reason for today's tele-inspection.

LPA and licensee discussed the death that occurred and the status of the facility. LPA discussed the Department's concerns regarding the licensing of the facility. The situation evolving may impact the license and the residents in care. LPA requested her to follow up with the co-applicant and to contact LPA with an update regarding the application status, staffing concerns, and if the application for the new licensee is still going to be pursued. She agreed and said she will meet with the co-applicant today to discuss these concerns and will contact LPA with an update. LPA also requested that if a copy of the application could be sent to LPA to see what was sent to Sacramento for processing. She also agreed to follow up with that information as well. Reporting requirements were discussed.

No deficiencies issued.

Report discussed with administrator and process in which the facility will receive a copy of this report and the e-signing of this document. A copy of this report is sent to the licensee via email and hardcopy via mail.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2021
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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