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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600936
Report Date: 11/01/2023
Date Signed: 11/01/2023 02:49:48 PM

Document Has Been Signed on 11/01/2023 02:49 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:
11/01/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:54 PM
MET WITH:Army NagumTIME COMPLETED:
02:45 PM
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On 11/1/2023, Licensing Program Analyst (LPA) Grace Donato conducted a case management visit concerning an incident report received on 10/30/23. LPA met with House Manager Army Nagum and explained the purpose of today's visit.

On 10/30/23, facility submitted an incident report concerning a resident (R1) was given a wrong medication.

In regard to the incident, stated that on the day the incident occurred, the staff (S1) was managing two residents that morning. S1 accidentally gave the wrong medication to R1. After noticing the accident, S1 called Poison Control and was advised to monitor and observe the resident. R1 stayed at home and per advise.

R1 is currently doing well and didn't have adverse side effects.

Facility is currently scheduled for In-Service staff training regarding medication administration. Proof will be sent to LPA once finished.

No deficiency cited today. Report is reviewed and copy is provided.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE: DATE: 11/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/01/2023
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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