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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600841
Report Date: 02/11/2025
Date Signed: 02/11/2025 04:15:03 PM

Document Has Been Signed on 02/11/2025 04:15 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:SAN BRUNO CARE HOMEFACILITY NUMBER:
415600841
ADMINISTRATOR/
DIRECTOR:
FORONDA-CAYABYAB, MARIE JFACILITY TYPE:
740
ADDRESS:1382 WILLIAMS AVENUETELEPHONE:
(650) 827-1382
CITY:SAN BRUNOSTATE: CAZIP CODE:
94066
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 6DATE:
02/11/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Caregiver, Ruben CabreraTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
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On February 11, 2025 Licensing Program Analyst(LPA) Murial Han conducted an unannounced annual inspection. LPA was greeted by caregivers, Ruben Cabrera and Elizabeth Princesa and LPA explained the purpose of the visit. Administrators, Marie and Chris Cayabyab arrived and assisted with the 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) and 1 staff room. Rooms were spacious and included all required furnishings. Bathroom was observed equipped with paper towels, soap, grab bars, and non-skid mats. Hot water temperature in the kitchen, and bathroom was measured at 105- 111 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 8/8/2024. Fire drill records were reviewed.

A review of (5) resident files was conducted and noted on the LIC 858.
A review of (2) staff files was conducted and noted on the LIC 859.

LPA reviewed P& I/ Case Resource Records for 3 residents to be adequate.

During today's inspection, there were 3 residents present and 3 residents were attending the day program.
April CowanTELEPHONE: (650) 266-8889
Murial HanTELEPHONE: (619) 209-9761
DATE: 02/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/11/2025
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 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: SAN BRUNO CARE HOME
FACILITY NUMBER: 415600841
VISIT DATE: 02/11/2025
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During the tour of the facility, LPA observed the facility is under construction in the backyard. According to the administrators/Licensees, the facility has obtained a building permit to build an Accessory Dwelling Unit (ADU) in the backyard. LPA received a copy of the Building Permit and requested for the following documents by 2/15/2025: a copy of the revised facility sketch, a copy of the construction notification to the residents and/or their responsible parties, GGRC, and a copy of the plan to ensure resident's safety during the construction.

No deficiency cited today.

This report is reviewed and discussed with administrator/licensee. A copy is provided.
SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:

DATE: 02/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2025
LIC809 (FAS) - (06/04)
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