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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600816
Report Date: 01/13/2024
Date Signed: 01/13/2024 11:55:01 PM


Document Has Been Signed on 01/13/2024 11:55 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
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066



FACILITY NAME:PETES' PLACEFACILITY NUMBER:
415600816
ADMINISTRATOR:FRISCH, ANDREWFACILITY TYPE:
740
ADDRESS:1122 VALOTA ROADTELEPHONE:
(650) 363-2423
CITY:REDWOOD CITYSTATE: CAZIP CODE:
94062
CAPACITY:6CENSUS: 6DATE:
01/13/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Administrator Andrew FrischTIME COMPLETED:
05:00 PM
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
Licensing program Analyst (LPA) Jason Lund arrived unannounced to conduct an annual/required visit. LPA met with, Andrew Frisch, administrator, and explained the purpose of the visit. Census: 6

LPA Lund & administrator Andrew Frisch toured/inspected. Facility temperature is 70 degrees. No pools or bodies of water were observed during today's visit. LPA observed at least one week of nonperishable and two (2) days of perishable foods. Toxic chemicals are stored away in a locked cabinet underneath the kitchen sink. Centrally stored medications are locked in a cabinet inside the staff office. Each resident room is equipped with a bed for each resident working lights and a nightstand. Facility has functioning smoke detectors. Fire extinguishers are full and were last inspected on 9/18/2023. LPA toured the backyard with Andrew. All outdoor and indoor passageway are free and clear of obstruction. LPA reviewed two residents. Residents’ records contained a signed admission's agreement, signed personal rights statement, completed medical assessment and a completed needs and service plan. medication administration record and centrally stored medication destruction record were reviewed for R1 and R2. No errors were observed by LPA.

No deficiencies during today's visit and report left.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Jason LundTELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:
DATE: 01/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/13/2024
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