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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600897
Report Date: 03/12/2025
Date Signed: 03/12/2025 04:35:39 PM

Document Has Been Signed on 03/12/2025 04:35 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:REDWOOD ACRES RESIDENTIAL HOMEFACILITY NUMBER:
415600897
ADMINISTRATOR/
DIRECTOR:
SARMIENTO, ANNA MARISSA V.FACILITY TYPE:
740
ADDRESS:1728 REDWOOD AVENUETELEPHONE:
(650) 361-1014
CITY:REDWOOD CITYSTATE: CAZIP CODE:
94061
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 6DATE:
03/12/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:33 PM
MET WITH:Masalina Victoriano, Administrator TIME VISIT/
INSPECTION COMPLETED:
04:45 PM
NARRATIVE
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On 3/12/2025, Licensing Program Analyst(LPA) John Calandra arrived at the facility to conduct the Annual 1-year required inspection. LPA Calandra was greeted by Enrico "Eric" Victoriano, Caregiver and Masalina Victoriano, Administrator and explained the purpose of the visit.

LPA toured the physical plant. This is a 1-story building with 7 bedrooms (6 for residents and 1 for staff) and 3 bathrooms, a living room, dining room, kitchen, and outdoor space/backyard. All bedrooms had the required furniture and sufficient lighting. No accessible bodies of water or hazards were observed in hallways or the backyard. The facility's fire alarms and Carbon Monoxide detector were observed to be in working order. The facility's first aid kit was observed to have all required items. The facility had the required 7 days of non perishables and 2 days of perishables on site. No food was expired. The facility was maintained at a comfortable temperature of 70 degrees Fahrenheit. The facility's hot water was measured between the required 105-120 degrees Fahrenheit. The facility's fire extinguishers were last serviced on 3/6/2024.

All sharp objects, poisons, and detergents were observed to be locked and in-accessible to persons in care.

LPAs reviewed 5 resident records and 5 staff files. All were observed to be complete. This facility does not handle cash for residents.

A review of Centrally stored medications indicated that medications for residents were properly labeled with instructions on dosage and times of day and matched the Centrally Stored Medication records kept at the facility.

A Type B Violation was provided for not having documentation of the facility's last emergency drill.

An exit interview was conducted. This report was reviewed with Masalina Victoriano, Administrator and a copy of the report left at the facility.
Andrea MedlinTELEPHONE: (650) 266-8811
John CalandraTELEPHONE: 650-266-8800
DATE: 03/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/12/2025
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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Document Has Been Signed on 03/12/2025 04:35 PM - It Cannot Be Edited

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: REDWOOD ACRES RESIDENTIAL HOME

FACILITY NUMBER: 415600897

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 03/12/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
HSC
1569.695(c)
HSC 1569.695(c): Emergency Plans: A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on document review, the licensee could not provide documentation of their last quarterly emergency drill, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/02/2025
Plan of Correction
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Licensee/Administrator to schedule an emergency drill and provide documentation to the Department by the Plan of Correction due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Andrea MedlinTELEPHONE: (650) 266-8811
John CalandraTELEPHONE: 650-266-8800

DATE: 03/12/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/12/2025

LIC809 (FAS) - (06/04)
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