<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600769
Report Date: 09/16/2021
Date Signed: 09/16/2021 11:20:47 AM

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: 2DATE:
09/16/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Mayanne AvenaTIME COMPLETED:
11:15 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 09/16/2021 at 0900hrs Licensing Program Analyst (LPA) Jaime Vado and Komal Charitra conducted an unannounced follow up prelicensing inspection visit. LPA met with licensee/administrator Mayanne and explained purpose of today's inspection.

LPAs made observations within the facility. LPAs inspected three facility bathrooms and all are in good condition. Faucets operate appropriately. Water temperatures are taken at all three faucets. Main bathroom located adjacent to living room water temp is 112F. Bathroom in hallway faucet temperature is measured at 107F. Bathroom water temp in resident room is measured at 107F. Facility is observed as clean with no debris and floors are clean. Facility fire drill log is observed as current. Last fire drill was conducted on 08/14/21. Backyard is observed as clear of boxes that were previously there on prior visit. Cleaning solutions are observed in locked hallway closet. Facility PPE is present. Facility food supplies are in place. Kitchen is observed as clean.

The following POCs are cleared during today's inspection:

Maintenance and Operation - Hot water temperature was measured at 125F in bathroom adjacent to living room.

Storage Space - Cleaning solutions are observed in the hallway closet did not have a locking mechanism installed at time of inspection.

Maintenance and Operation - LPA observed debris on the floors through out facility, dried water foot prints near living room bathroom, water faucets in resident room and hallway bathroom do not function properly not allowing appropriate water flow. Areas around faciilty observed with dust and spider webs.

Fire and earthquake drills shall be conducted at least once every three months on each shift and shall include, at a minimum, all direct care staff - LPA requested to view fire drill log but the log was not able to be found and licensee could not provided exact date of last drill conducted.

Report is reviewed with administrator.

No citations issued.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 1