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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600936
Report Date: 09/05/2023
Date Signed: 09/05/2023 04:18:52 PM

Document Has Been Signed on 09/05/2023 04:18 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:KIMAYA HOMEFACILITY NUMBER:
415600936
ADMINISTRATOR:ARMY LAIZZEA A NAGUMFACILITY TYPE:
735
ADDRESS:527 ORANGE AVETELEPHONE:
(650) 741-6595
CITY:SOUTH SAN FRANCISCOSTATE: CAZIP CODE:
94080
CAPACITY: 4CENSUS: 4DATE:
09/05/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:35 PM
MET WITH:Kimberly MartinTIME COMPLETED:
03:45 PM
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On 9/5/23 LPA Grace Donato made an unannounced annual visit to the facility. LPA met with Administrator Kimberly Martin and explained the purpose of the visit.

LPA toured the facility inside and outside including all of resident rooms, garage, and kitchen area. One resident is back from Adult Day Program. Three residents went on an outing with caregivers just before LPA arrived. While touring the facility it was observed that the room temperature was at 72 deg F. Hot water was also tested in the bathrooms and the temperature was 105 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 in the kitchen cabinet and underneath the sink and inaccessible to residents. Food supply in kitchen and freezer located in garage was observed with an adequate two day perishable and seven day non-perishable food supply. Carbon monoxide/ smoke detectors, and fire extinguisher were present throughout the facility and has been checked on 8/24/23. Facility has an updated log for emergency drill which is done every three months.

Two resident records and three staff records were reviewed. Resident’s PNI money was counted and all accounted for with proper log and receipts. Staff have criminal record and fingerprint clearances on file. Staff have current First Aid/CPR certifications on file. Resident records were reviewed and were observed to be complete. Medication was locked inaccessible by residents. Centrally stored medication logs are complete and updated.

LPA requested to submit the following and was received in the facility at 9/5/2023: LIC 309, LIC 308, LIC 500, LIC 610D, Surety Bond, Administrator Certificate.

No deficiencies are cited at this time. Report is reviewed and a copy is provided.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE: DATE: 09/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/05/2023
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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