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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600841
Report Date: 02/08/2024
Date Signed: 02/08/2024 06:04:46 PM


Document Has Been Signed on 02/08/2024 06:04 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
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066



FACILITY NAME:SAN BRUNO CARE HOMEFACILITY NUMBER:
415600841
ADMINISTRATOR:FORONDA-CAYABYAB, MARIE JFACILITY TYPE:
740
ADDRESS:1382 WILLIAMS AVENUETELEPHONE:
(650) 827-1382
CITY:SAN BRUNOSTATE: CAZIP CODE:
94066
CAPACITY:6CENSUS: 6DATE:
02/08/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Caregiver, Jennie PacayTIME COMPLETED:
12:20 PM
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On 2/8/2024 Licensing Program Analyst(LPA) Murial Han conducted an unannounced annual inspection. LPA was greeted by caregiver, Jennie Pacay and LPA explained the purpose of the visit. Administrators, Marie and Chris Cayabyab arrived shortly thereafter to assist with inspection.

LPA toured facility and grounds. No accessible bodies of water or fire safety hazards observed. LPA toured the facility inside and outside including all of resident rooms, common areas, and kitchen area. The indoor and outdoor passageways were free of obstruction. Facility was overall clean and odor-free. Comfortable temperature is maintained and lighting is sufficient for comfort.

LPA observed 5 resident rooms (4 private and 1 shared rooms). Rooms were spacious and included all required furnishings. Two full bathrooms were observed to be clean; equipped with paper towels, soap, grab bars, and non-skid mats. Hot water temperature in the kitchen, and bathroom was measured at 106 degree F. Extra linen was present. Medications, toxins and sharps were observed to be locked. 2 days for perishables and & 7 days non-perishable were observed to be present.

Facility is equipped with smoke detectors and carbon monoxide detectors. Fire extinguisher were last serviced in 8/31/2023. Fire drill records were reviewed.

LPA reviewed 5 resident records and all of them contained Admission Agreement, Medical Assessment- LIC 602 (Physician Order), Appraisal Needs and Service Plan, Resident Identification information, Pre-Placement Appraisals, GGRC/IPP, etc.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:
DATE: 02/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/08/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: SAN BRUNO CARE HOME
FACILITY NUMBER: 415600841
VISIT DATE: 02/08/2024
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LPA reviewed 2 staff files and all of them contained Personnel Records, Training Records, Health Screening Records, Job Description, Abuse Statement, First Aid/CPR, Criminal Record Statement, Criminal Background Clearance, etc.

LPA reviewed P& I/ Case Resource Records for 4 residents to be adequate.

During today's inspection, there were 5 residents present and 1 resident was attending the day program.

LPA request for the following documents to be submitted by 2/9/2024: LIC 400 (Affidavit Regarding Client/Resident Cash Resources), Lease Agreement, LIC 308 (Designation of Facility Responsibility), Administrator Certification and Surety Bond.

No deficiency cited today.

This report is reviewed and discussed with administrators. A copy is provided.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:

DATE: 02/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2024
LIC809 (FAS) - (06/04)
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