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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600832
Report Date: 05/07/2024
Date Signed: 05/07/2024 04:14:18 PM


Document Has Been Signed on 05/07/2024 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:JOYFUL CHAPTERFACILITY NUMBER:
415600832
ADMINISTRATOR:ROBERT WONGFACILITY TYPE:
740
ADDRESS:340 ALTA VISTA DRIVETELEPHONE:
(650) 827-5228
CITY:SOUTH SAN FRANCISCOSTATE: CAZIP CODE:
94080
CAPACITY:49CENSUS: 46DATE:
05/07/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:19 PM
MET WITH:Sharon WongTIME COMPLETED:
04:45 PM
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On 5/7/24, LPA Grace Donato made an unannounced annual visit to the facility. LPA met with Administrator Sharon Wong. LPA explained the purpose of the visit.

LPA toured the facility inside and outside including a random sample of resident rooms, common areas & kitchen area. The indoor and outdoor passageways were free of obstruction. LPA observed some residents were in the activity room doing some activities or watching TV, there were also residents resting in the bedrooms. Hot water was also tested in the bathrooms and the temperature was 108 deg F. The residents have adequate amount of linens and incontinence care items. All personal belongings are intact. Carbon monoxide monitors are working properly. All fire extinguishers have been checked and current. Resident bedrooms and bathrooms were observed to be in good repair. Bathrooms are equipped with grab bars and non-skid mats. 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.

LPA reviewed five resident records and five staff records. Resident records are updated, complete and signed. Staff records are complete, with training logs. Facility has a certified administrator on site with complete certification and training requirements. Facility accepts hospice residents and are in compliance with the required waiver requirements. Medication review was done, and all medications are accounted for, and centrally stored medication records are updated.

LPA requested submitted the following: LIC 500, Liability Insurance & Administrator Certificate.

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: 05/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/07/2024
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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