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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600827
Report Date: 02/18/2025
Date Signed: 02/18/2025 04:18:25 PM

Document Has Been Signed on 02/18/2025 04:18 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:CAMENCHITA'S RESIDENTIAL CARE HOMEFACILITY NUMBER:
415600827
ADMINISTRATOR/
DIRECTOR:
JAVINIAR-CRUZ DIAZ, ROWENAFACILITY TYPE:
740
ADDRESS:419 HAZELWOOD DRIVETELEPHONE:
(650) 745-8441
CITY:SOUTH SAN FRANCISCOSTATE: CAZIP CODE:
94080
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 4DATE:
02/18/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:14 PM
MET WITH:Rowena DiazTIME VISIT/
INSPECTION COMPLETED:
04:30 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
On 2/18/2025, LPA Grace Donato made an unannounced annual visit to the facility. LPA met with Administrator Rowena Diaz. LPA explained the purpose of the visit.

LPA toured the facility inside and outside including all of resident rooms, and kitchen area. While touring the facility it was observed that the room temperature was at 70 deg F. Hot water was also tested in the bathrooms and the temperature was 110 deg F. The facility is observed to be clean, odorless, and well maintained. Residents bedrooms were observed to be well organized and fully furnished with adequate lighting. Sharps and toxic materials were observed locked in a cabinet. Food supply was observed with an adequate two day perishable and seven day non-perishable. Carbon monoxide/smoke detectors, and fire extinguisher were present throughout the facility. Facility has an updated log for emergency drill are done every quarter.

Four resident records and four staff records were reviewed. Centrally stored medication was locked in the medicine cart and inaccessible by residents. All medication was labeled and sorted by resident name. All medication logs are complete and updated.

LPA requested licensee to submit the following: LIC308, Liability Insurance.

No deficiencies are cited at this time. Report is reviewed with licensee and a copy is provided
Andrea MedlinTELEPHONE: (650) 266-8811
Grace DonatoTELEPHONE: (714) 293-8294
DATE: 02/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/18/2025
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