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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600970
Report Date: 10/18/2023
Date Signed: 10/18/2023 06:18:13 PM

Document Has Been Signed on 10/18/2023 06:18 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:CRESTMOOR HOMEFACILITY NUMBER:
415600970
ADMINISTRATOR:RAQUINIO, ROMARFACILITY TYPE:
735
ADDRESS:3498 CRESTMOOR DRIVETELEPHONE:
(650) 387-9488
CITY:SAN BRUNOSTATE: CAZIP CODE:
94066
CAPACITY: 4CENSUS: 4DATE:
10/18/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Lead Staff, Rodolfo Marcos Jr.TIME COMPLETED:
01:10 PM
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On October 18, 2023 Licensing Program Analyst(LPA) Murial Han conducted an unannounced annual inspection. LPA was greeted by lead staff, Rodolfo (Rudy) Marcos Jr. and administrator and licensee arrived shortly thereafter to assist with the inspection.

LPA toured the facility inside and outside including the bedrooms (4 private rooms), 2 full- bathrooms, kitchen, and common areas. The facility observed to clean, tidy and in good repair. Bedrooms were equipped with the required furniture for residents to use. Bathrooms are equipped with grab bars, and nonskid mats. Facility temperature is comfortable. Hot water temperature was measured at 102- 108 degrees F.

Central stored medication, toxins and sharps objects were locked and inaccessible to residents.

Staff training records were reviewed; food supplies were observed to be adequate,

Facility is equipped with smoke detectors and carbon monoxide detectors.

LPA reviewed 4 residents files and all of them contained admission agreement, medical assessment, LIC 602 (Physician Order), Appraisal Needs and Service Plan, GGRC/IPP, and etc.

LPA reviewed 3 staff files that contained personnel records, health screening, Job Description, Abuse Statement, First Aide and CPR, Criminal Record Statement.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE: DATE: 10/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/18/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: CRESTMOOR HOME
FACILITY NUMBER: 415600970
VISIT DATE: 10/18/2023
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LPA reviewed P & I records to be accurate.

During today's inspection, there are 1 resident present and 3 were attending the adult day program.

No deficiency cited today.

This report is reviewed and discussed with the administrator and lead staff. A copy is provided.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:

DATE: 10/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2023
LIC809 (FAS) - (06/04)
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