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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600936
Report Date: 06/07/2024
Date Signed: 06/07/2024 03:08:10 PM

Document Has Been Signed on 06/07/2024 03:08 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:KIMAYA HOMEFACILITY NUMBER:
415600936
ADMINISTRATOR/
DIRECTOR:
ARMY LAIZZEA A NAGUMFACILITY TYPE:
735
ADDRESS:527 ORANGE AVETELEPHONE:
(650) 741-6595
CITY:SOUTH SAN FRANCISCOSTATE: CAZIP CODE:
94080
CAPACITY: 4CENSUS: 4DATE:
06/07/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:15 PM
MET WITH:Licensee - Ian MauricioTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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On 06/07/2024, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced infection control annual inspection. LPA met with licensee Ian Mauricio and explained purpose of today's inspection.

LPA was allowed entry into the facility. This is a one level facility. Annual Fees are current. The physical plant was toured inside and outside to ensure the safety of the residents. LPA observed the facility kitchen which is clean and observed appliances are in good repair. Knives are stored in the kitchen locked in a drawer adjacent to the oven. Cleaning solutions are also locked below the sink as well in the garage. Perishable and non-perishable food items are observed as in place. LPA observed the medications as in place and locked in a closet in the living room. The first aid kit observed is complete with required items. LPA observed that the facility is equipped with full sprinkler system, fire extinguishers are placed through out the facility inspected 05/15/24, smoke detector/carbon monoxide detectors are observed in place, and central heating system. PPE and additional food supplies are observed as in place in the garage. Laundry area is also observed as fully operational located in the garage. Emergency exit routes are observed inside and outside to be free and clear of obstructions. Water temperature was measured at 107F. LPA observed two resident rooms at random and both rooms appeared clean, free of odors, and contained all the required furniture per regulatory recommendations. COVID PPE and resident incontinence supplies are observed in place in the garage. Disaster drills take place monthly per records observed. Last taking place on 05/30/2024.

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SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Jaime Vado
LICENSING EVALUATOR SIGNATURE: DATE: 06/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/07/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: KIMAYA HOME
FACILITY NUMBER: 415600936
VISIT DATE: 06/07/2024
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LPA reviewed 2 resident files of 4 residents. LPA also reviewed 2 staff files on this day. All files are current per review made. P&I is handled by the facility and per review of the monies of both residents are current and logged accurately. Administrator certificate is observed as current expiring on 08/15/2025. LPA also observed clients and staff present and there appears to be not distress between clients and staff. Both clients present are with staff and are engaging with them.

The following updated forms are requested to be submitted to CCLD by 06/14/2024:

• Updated Administrator Certificate
• Updated surety bond with expiration date
• LIC 308 Designation of Administrative Responsibility
• LIC400 Affidavit Regarding Client/Resident Cash Resources
• LIC610D Emergency Disaster Plan

No citations issued. Report is reviewed licensee. Copy is provided.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Jaime Vado
LICENSING EVALUATOR SIGNATURE:

DATE: 06/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2024
LIC809 (FAS) - (06/04)
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