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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600821
Report Date: 09/03/2024
Date Signed: 09/03/2024 04:14:38 PM


Document Has Been Signed on 09/03/2024 04:14 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 SWEET HOME SENIOR CAREFACILITY NUMBER:
415600821
ADMINISTRATOR:IREN LUDNAYFACILITY TYPE:
740
ADDRESS:1560 BRYANT STREETTELEPHONE:
(650) 992-2727
CITY:DALY CITYSTATE: CAZIP CODE:
94015
CAPACITY:55CENSUS: 31DATE:
09/03/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH: Irena MatijasTIME COMPLETED:
04:20 PM
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On September 03, 2024, Licensing Program Analysts (LPAs) Grace Donato and Kiran Jain arrived at the facility at 01:15 PM to conduct the Annual 1-year required inspection. LPAs met with Irena Matijas, Licensee/Administrator, and Therisa Pamintuan, Lead Staff, and explained the purpose of the visit.

LPAs toured the physical plant. The facility is a two-story, clean, and well-maintained building. All bedrooms, living room, dining room, common area, elevator, and backyard were observed to be in good condition. No accessible bodies of water or other hazards were observed. Fire extinguishers were fully charged and last serviced on April 2024. Smoke detectors and carbon monoxide detectors were observed to be in working condition. Adequate lighting and indoor temperature readings at 75°F were observed in the common room.

LPAs inspected five resident rooms and two resident bathrooms. Rooms were observed to be clean with sufficient furniture and lighting. The bathrooms were observed to be mold-free and contained liquid soap and paper towels. The bath area had a shower curtain and a shower chair. The hot water temperature in the bathroom sink faucet was measured at 107.8°F.



The kitchen was observed to be clean without any knives, sharp objects, or chemicals seen accessible to persons in care. No expired food items were observed. The facility had the required 7 days of non-perishables and 2 days of perishables items.

LPA reviewed five resident records and five staff records. All were observed to be complete. The client’s medications were securely stored in a locked room inaccessible to the residents. The First Aid kit was checked and found to have the required items.



Updated LIC 500: Personnel Report form is requested to be submitted to CCLD by 09/06/2024.

No deficiencies were cited during today's visit. An exit interview was conducted. This report was reviewed with
Irena Matijas and Theresa Pamintuan and a copy of this report was left at the facility.
SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Kiran JainTELEPHONE: 650-416-4836
LICENSING EVALUATOR SIGNATURE:
DATE: 09/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/03/2024
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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