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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600934
Report Date: 06/21/2024
Date Signed: 06/21/2024 02:46:08 PM


Document Has Been Signed on 06/21/2024 02:46 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:ICAREFACILITY NUMBER:
415600934
ADMINISTRATOR:MIRANDA-SUNGA, SHERYLL APHFACILITY TYPE:
740
ADDRESS:714 SOUTHWOOD DRIVETELEPHONE:
(650) 243-8889
CITY:SOUTH SAN FRANCISCOSTATE: CAZIP CODE:
94080
CAPACITY:6CENSUS: 5DATE:
06/21/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:55 PM
MET WITH:Dominga EscanoTIME COMPLETED:
03:00 PM
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On 6/21/2024, LPA Grace Donato made an unannounced annual visit to the facility. LPA met Caregiver Dominga Escano. LPA explained the purpose of the visit.

LPA toured the facility inside and outside including resident rooms, common areas, kitchen area and garage. The indoor and outdoor passageways were free of obstruction. LPA observed a resdient watching tv and later two residents arrived from day program. A comfortable temperature of 69 deg F is maintained and lighting is sufficient for comfort. Hot water was also tested in the bathrooms and the temperature was 115 deg F. The residents have adequate number of linens and incontinence care items. All personal belongings are intact. Carbon monoxide monitors are working properly. All fire extinguishers have been checked and current. Resident bedrooms and bathrooms were observed to be in good repair equipped with grab bars and non-skid mats. LPA checked the food supply and there is adequate amount of food, 2 days for perishables and & 7 days non-perishable. Emergency drills are logged and done every quarter. LPA observed sharps, toxins and chemicals to be locked and inaccessible to residents.

LPA reviewed three resident records and three staff records. Resident records are updated, complete and signed. Staff records are complete, with training logs. Facility accepts hospice residents and are in compliance with the required waiver requirements. Medication review was done, and all medications are accounted for, and centrally stored medication records are updated.

LPA requested the following documents: LIC500, Surety Bond & Liability Insurance.

No deficiency is being cited today. Report is reviewed and copy is provided.
SUPERVISOR'S NAME: Andrea MedlinTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Grace DonatoTELEPHONE: (714) 293-8294
LICENSING EVALUATOR SIGNATURE:
DATE: 06/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/21/2024
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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