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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600971
Report Date: 12/07/2023
Date Signed: 12/08/2023 08:07:00 AM

Document Has Been Signed on 12/08/2023 08:07 AM - 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:NORTH PENINSULA DAY SERVICESFACILITY NUMBER:
415600971
ADMINISTRATOR:MARIBETH LUCEROFACILITY TYPE:
775
ADDRESS:3560 CALLAN BLVDTELEPHONE:
(650) 952-5165
CITY:SOUTH SAN FRANCISCOSTATE: CAZIP CODE:
94080
CAPACITY: 45CENSUS: 22DATE:
12/07/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Mary Grace MercadoTIME COMPLETED:
01:45 PM
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On 12/7/23 LPA Grace Donato made an unannounced annual visit to the facility. LPA met with Program Supervisor, Mary Grace Mercado. LPA explained the purpose of the visit.

LPA toured the facility including all of activity rooms, common areas & kitchen. The indoor and outdoor passageways were free of obstruction. LPA observed clients doing activities such as arts & crafts, watching movies, therapy. Staff has been prepping lunch when LPA arrived. While touring the facility it was observed that the room temperature was at 70 deg F. Hot water was also tested in the bathrooms and the temperature was 116 deg F. Carbon monoxide monitors are working properly. All fire extinguishers have been checked and current. Client bathrooms were observed to be in good repair equipped with grab bars. Changing rooms are equipped with changing tables and supply of incontinent items. Food are brought in by residents prepared from their home facilities. Snacks are provided. Chemicals are in locked cabinets. Laundry room is also locked with code. Emergency drills are done quarterly.

Five client records and five staff records were reviewed. Resident records are updated, complete and signed. Staff records are complete, with training logs. Facility has a certified administrator on site LPA also interviewed 3 staff members.

LPA received the following from facility: Liability Insurance, LIC 500, LIC 610D & LIC 308.

No deficiencies are cited at this time. Report is reviewed and a copy is provided.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE: DATE: 12/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/07/2023
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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