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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600901
Report Date: 08/08/2024
Date Signed: 08/08/2024 04:12:16 PM

Document Has Been Signed on 08/08/2024 04:12 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:DERRY WAY HOME, INC.FACILITY NUMBER:
415600901
ADMINISTRATOR/
DIRECTOR:
KWAI KWONG LIUFACILITY TYPE:
740
ADDRESS:2243 DERRY WAYTELEPHONE:
(650) 219-7930
CITY:SOUTH SAN FRANCISCOSTATE: CAZIP CODE:
94080
CAPACITY: 8CENSUS: 4DATE:
08/08/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:25 PM
MET WITH:Yvonne KwokTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
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On 8/8/2024 LPA Grace Donato made an unannounced annual visit to the facility. LPA met with Administrator Yvonne Kwok . LPA explained the purpose of the visit.

LPA toured the facility inside and outside including all of resident rooms, garage, and kitchen area. Facility is a two-story house with resident rooms on the second floor. Residents are currently in the day program. While touring the facility it was observed that the room temperature was at 68 deg F. Hot water was also tested in the bathrooms and the temperature was 110 deg F. The facility is observed to be clean, odorless, and well maintained. Residents bedrooms were observed to be well organized and fully furnished with adequate lighting. Sharps and toxic materials were observed locked. Food supply was observed with an adequate with two day perishable and seven day non-perishable food supply. Carbon monoxide/smoke detectors, and fire extinguisher were present throughout the facility.

Four resident records and four staff records were reviewed. Staff have criminal record and fingerprint clearances on file. Resident records were reviewed and were observed to be complete with documents such as Admission Agreements, Medical Assessments, and Needs and Service Plans. Medication review was done, and all medications are accounted for, and centrally stored medication records are updated.

LPA requested LIC 500 to be emailed. LPA received copy of Liability Insurance.

No deficiencies are cited at this time. Report is reviewed with Administrator and a copy is provided.
SUPERVISORS NAME: Andrea Medlin
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE: DATE: 08/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/08/2024
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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