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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600911
Report Date: 02/02/2024
Date Signed: 02/02/2024 12:26:03 PM


Document Has Been Signed on 02/02/2024 12:26 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
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066



FACILITY NAME:ANGEL HAVENFACILITY NUMBER:
415600911
ADMINISTRATOR:GIUSTO, FERLENEFACILITY TYPE:
740
ADDRESS:1660 WOLFE DRIVETELEPHONE:
(650) 458-6166
CITY:SAN MATEOSTATE: CAZIP CODE:
94402
CAPACITY:6CENSUS: 6DATE:
02/02/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Administrator, Ferlene GuistoTIME COMPLETED:
12:40 PM
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On February 2, 2024, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced annual inspection. LPA met with Administrator, Ferlene Guisto and explained the purpose of the visit.

LPA toured facility and grounds. The indoor and outdoor passageways were free of obstruction. No accessible bodies of water of fire safety hazards observed. This is a single story facility with 6 resident private bedrooms, 1 staff room, and 3 bathrooms. LPA observed resident bedrooms with all required furniture. Door alarms from each resident room to the outside passageway was observed to be in good working condition. Bathrooms were observed to be clean and in good repair; equipped with non-skid mats, toilet paper and liquid soap. Kitchen was observed, 2 day perishable and 7 day non-perishable was present. Toxins, sharps, and medication were locked and stored appropriately and inaccessible to residents.

Living room and dining room was observed to be clear and free from tripping hazards. A comfortable temperature is maintained at 71 degrees F and lighting is sufficient for comfort. Extra linen was present and first aid kit was observed to be completed. Carbon monoxide monitors are working properly. All fire extinguishers have been checked and current as of June 2023. Emergency drills are logged and done every three months.

LPA reviewed 5 resident records and 5 staff records. Resident records are updated, complete and signed. Staff records are complete, with training logs that have met the basic requirement. Medication review was done, and all medications are accounted for, and centrally stored medication records are updated.

No citations are issued during this visit. Report is reviewed with Administrator and a copy is provided.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 02/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/02/2024
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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