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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600863
Report Date: 02/18/2025
Date Signed: 02/18/2025 05:26:14 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 02/18/2025 05:26 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:A & E HOME CARE SERVICESFACILITY NUMBER:
415600863
ADMINISTRATOR/
DIRECTOR:
TRIA, ARMANDO Z.FACILITY TYPE:
740
ADDRESS:1615 DIX STREETTELEPHONE:
(650) 574-5994
CITY:SAN MATEOSTATE: CAZIP CODE:
94401
CAPACITY: 6CENSUS: 0DATE:
02/18/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
04:30 PM
MET WITH:Rebecca TriaTIME VISIT/
INSPECTION COMPLETED:
05:30 PM
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LPA Audrey Jeung toured facility and grounds, including detached storage building. This one level home consists of 4 client bedrooms--3 with 2 beds and one with single bed--a staff room, 2 full bathrooms, staff room adjacent to kitchen with half bathroom, living room, dining room, and kitchen. Washer and dryer are located in attached 2-car garage. There are no accessible bodies of water or fire safety hazards observed. Carbon monoxide detector is tested and operable. There are lockable cabinets for secure storage of medications and toxins. A comfortable room temperature is maintained, and lighting is sufficient for safety. First-aid kit is maintained and complete. A Disaster and Mass Casualty Plan is posted. There are several persons who maintain criminal record clearances, including Ms. Tria.
RCFE administrator certificates for Armando and Elizabeth Tria are observed--both expired in 2023.

Licensee is requested to notify CCLD within 5 days of admitting a client. It is noted that facility phone number is disconnected and there is no new number. Upon admission of resident, a land line phone is REQUIRED.

The following information and/or documents are requested to be updated and submitted to CCLD prior to admission of resident:

- Designation of Administrative Responsibility (LIC308)
- Personnel Report (LIC500)
- Emergency Disaster Plan (LIC610E--9 page revision)
- Proof of current liability insurance
- Valid RCFE administrator certificate



No deficiencies cited.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Audrey Jeung
LICENSING EVALUATOR SIGNATURE: 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)
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