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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600925
Report Date: 09/18/2023
Date Signed: 09/18/2023 11:14:03 AM

Document Has Been Signed on 09/18/2023 11:14 AM - 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:CALIFORNIA ASSISTED DEVELOPMENT LLCFACILITY NUMBER:
415600925
ADMINISTRATOR:LOCHIN, STACYFACILITY TYPE:
775
ADDRESS:3641 HAVEN AVENUE, STE ATELEPHONE:
(415) 573-7031
CITY:MENLO PARKSTATE: CAZIP CODE:
94025
CAPACITY: 40CENSUS: 12DATE:
09/18/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Program Director, Stacy Lochin TIME COMPLETED:
11:30 AM
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On September 18, 2023, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced annual inspection. LPA met with Assistant Program Director, Dabatha Sequeira and Program Director, Stacy Lochin and explained the purpose of the visit.

LPA toured facility and grounds. No accessible bodies of water or fire safety hazards observed. LPA observed a storage room to the right of the entrance door where client's store their belongings. There are 4 classrooms and an open main area observed. Classrooms were observed to be clean. Outdoor activity space was observed to be fenced and clear from tripping hazards. Facility overall is clean. A comfortable temperature is maintained and lighting is sufficient for comfort.

LPA observed chemicals and toxins locked and inaccessible to clients. Kitchen was observed to be clean and free from odor. According to the assistant director, the kitchen door stays locked at all times. Sharps were observed to be locked. Clients are able to utilize the kitchen to store their lunches that they bring from their homes. A supply of snacks were observed. There were two separate bathrooms observed for women and men. Bathrooms were equipped with liquid soap, paper-towels, and hand washing signage. First aid kit was observed to be complete.

LPA toured the second floor of the facility which is used as an open conference room with an office. Three desks were present with computers. A storage room was observed. Facility has 3 vans that were last serviced on 06/2023. LPA reviewed 6 clients files and 5 staff files. LPA observed all files to be complete and up-to-date.

Program Director to submit the follow documents to CCLD by 9/25/2023:
-LIC500 Personnel Report
-LIC610D Emergency Disaster Plan
-LIC308 Designation of Administrative Responsibility

No deficiencies cited during the visit. Report is reviewed with Program Director and a copy is provided.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE: DATE: 09/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/18/2023
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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