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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600816
Report Date: 05/08/2024
Date Signed: 05/08/2024 03:12:54 PM


Document Has Been Signed on 05/08/2024 03:12 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: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:
05/08/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Administrator - Andy FrischTIME COMPLETED:
03:30 PM
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On 05/08/2024, Licensing program Analyst (LPA) Jaime Vado conducted an unannounced required - 1 year inspection. LPA met with Administrator Andrew Frisch and explained the purpose of today’s visit.

This is a two level facility but all clients live on the ground. Facility temperature is comfortable for residents and staff. No pools or bodies of water were observed during today's visit. LPA observed that one week of nonperishable and two (2) days of perishable foods are in place. 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 observed to contain the required furniture as outlined in title 22 regulations. 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. Disaster drills are completed quarterly. Last drills on record 04/02/2024 and 04/12/2024 for earthquakes and fires.

LPA reviewed 2 resident files and both are current. Facility does handle resident monies at this location. Resident P&I is counted and reviewed as accurate. LPA was provided a copy of the surety bond for resident monies and is current. LPA reviewed 4 staff files on this day and all are current with required documents and training. Administrator certificate is reviewed as current expiring 06/17/2025. A copy of the administrator certificate is provided to LPA on this day as well.

The following updated forms are being requested to be received by 05/15/2024:

• LIC610D Emergency Disaster Plan
• LIC 308 Designation of Administrative Responsibility
• LIC 500 Personnel Report
• LIC9020 Client Roster
• Certificate of Liability Insurance
• Control of Property


No citations issued. Report is reviewed the administrator Andy Frisch.
SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8865
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:
DATE: 05/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/08/2024
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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