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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600827
Report Date: 02/06/2024
Date Signed: 02/06/2024 02:45:46 PM


Document Has Been Signed on 02/06/2024 02:45 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:JAVINIAR-CRUZ DIAZ, ROWENAFACILITY TYPE:
740
ADDRESS:419 HAZELWOOD DRIVETELEPHONE:
(650) 745-8441
CITY:SOUTH SAN FRANCISCOSTATE: CAZIP CODE:
94080
CAPACITY:6CENSUS: 6DATE:
02/06/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:29 PM
MET WITH:Rowena Diaz & Kevin ReyesTIME COMPLETED:
03:00 PM
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On 2/6/2024 LPA Grace Donato made an unannounced annual visit to the facility. LPA met with Caregiver Kevin Reyes and Administrator Rowena Diaz followed after. LPA explained the purpose of the visit.

LPA toured the facility inside and outside including all of resident rooms, common areas and kitchen. The indoor and outdoor passageways were free of obstruction. Two residents are having lunch, one resident in isolation due to covid and the others are in Adult Day Program. Resident bedrooms were observed to have necessary furniture. All personal belongings are intact. Resident’s bathrooms were observed to be in good repair equipped with grab bars and non-skid mats. Sharps and toxic materials were observed to be locked. While touring the facility it was observed that the room temperature was at 69 deg F. Hot water was also tested in the bathrooms and the temperature was 108 deg F. Carbon monoxide monitor is working properly. All fire extinguishers have been checked and current. LPA checked the food supply and there is adequate amount of food, 2 days for perishables and & 7 days non-perishable. Emergency drills are logged and done every quarter.

Six client records and four staff records were reviewed. Resident records are updated, complete and signed. Staff records are complete, with training logs.

Medication review was done, and all medications are accounted for, and centrally stored medication records are updated.

LPA requested documents: LIC 500, Certificate of Liability Insurance & Surety Bond.

No deficiencies are cited at this time. Report is reviewed and a copy is provided.
SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8865
LICENSING EVALUATOR NAME: Grace DonatoTELEPHONE: (714) 293-8294
LICENSING EVALUATOR SIGNATURE:
DATE: 02/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/06/2024
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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