<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600870
Report Date: 03/30/2023
Date Signed: 03/30/2023 05:11:35 PM

Document Has Been Signed on 03/30/2023 05:11 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:SWEETWOOD HOMEFACILITY NUMBER:
415600870
ADMINISTRATOR:ROBERTO BALAUROFACILITY TYPE:
735
ADDRESS:1311 SWEETWOOD DRIVETELEPHONE:
(650) 703-1217
CITY:DALY CITYSTATE: CAZIP CODE:
94015
CAPACITY: 4CENSUS: 4DATE:
03/30/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Administrator, Roberto BalauroTIME COMPLETED:
01:15 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 3/30/2023, Licensing Program Analyst(LPA) Murial Han and LPA Komal Charitra conducted an unannounced annual inspection. LPAs observed COVID-19 signs posted by the entrance. LPAs were greeted by administrator, Rob. LPAs explained the purpose of the visit and LPAs were screened at the front entrance.
5
The administrator assisted with the inspection and Licensees, Kevin Braud and Irene Monteclar arrived during the inspection.

LPAs toured the facility inside and outside including the bedrooms (4 private rooms), 2 full- bathrooms, kitchen, and common areas. The facility observed to clean, tidy and in good repair. Bedrooms were equipped with the required furniture for residents to use. Bathrooms are equipped with grab bars, and nonskid mats. Facility temperature is comfortable. Hot water temperature was measured at 118-119 degrees F.

Central stored medication, toxins and sharps objects were locked and inaccessible to residents.

Staff training records were reviewed; food supplies were observed to be adequate,

Facility is equipped with smoke detectors and carbon monoxide detectors. Fire extinguisher was last serviced May 24, 2022. Fire drill was last conducted on 1/9/2023.

Staff members at the facility were fingerprint cleared and associated to the facility.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE: DATE: 03/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/30/2023
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
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: SWEETWOOD HOME
FACILITY NUMBER: 415600870
VISIT DATE: 03/30/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
LPAs reviewed residents and staff records. Resident records contain admission agreement, medical assessment, LIC 602 (Physician Order), Appraisal Needs and Service Plan, GGRC/IPP, etc. Staff files contain personnel records, health screening, COVID-19 vaccination card, Job Description, Abuse Statement, First Aide and CPR, Criminal Record Statement.

LPAs reviewed the P & I records and observed Record of Client's/ Resident's Safeguarded Case Resources (LIC 405) and receipts for 3 residents.

During today's inspection, there are 1 resident present and 3 were attending the adult day program.

No deficiency cited today.

This report is reviewed and discussed with the administrator and licensees. A copy is provided.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:

DATE: 03/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2