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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600983
Report Date: 05/20/2024
Date Signed: 05/21/2024 07:10:00 AM


Document Has Been Signed on 05/21/2024 07:10 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:ANAMARIE CARE HOME LLCFACILITY NUMBER:
415600983
ADMINISTRATOR:AREVALO, ANA MARIEFACILITY TYPE:
740
ADDRESS:748 WASHINGTON STREETTELEPHONE:
(650) 550-4668
CITY:DALY CITYSTATE: CAZIP CODE:
94015
CAPACITY:6CENSUS: 5DATE:
05/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Administrator - Ana Marie ArevaloTIME COMPLETED:
02:15 PM
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On 5/20/2024, Licensing Program Analyst (LPA) Jaime Vado to conduct an unannounced Required -1 Year visit. LPA met with administrator Ana Marie Arevalo and explained the purpose of this visit.

LPA was allowed entry into the facility that is licensed to serve Age Range 60 and over of which 6 may be non -ambulatory. Hospice waiver for 2. Currently there is only 1 resident on hospice. Annual Fees are current. This is a one level facility. The physical plant was toured inside and outside to ensure the safety of the residents. The last documented emergency drill was conducted and recorded to be conducted in 03/08/24. LPA observed the medications area to locked in the kitchen in a cabinet adjacent to the sink. Sharps are also locked with the medications. Facility is equipped fire extinguishers, smoke and carbon monoxide detectors, central heating and air in the facility. The facilities fire detectors/carbon monoxide detectors are hardwired through out the facility according to Ana Marie. Fire extinguishers are observed with an inspection date of 08/30/2023. Water temperature tested in kitchen sink at 112F. Resident rooms are checked to contain operable lighting and all required furniture in accordance with regulations. Both 7 day and 2 day food supplies are observed to be in place. Laundry machine and dryer are in good working order located in the garage. PPE is observed as in place

LPA observed 3 staff and 2 resident files during this visit. The first aid kit was found in compliance containing the required items outlined in regulations. P&I monies are not handled by the facility. Administrator certificate expires as observed on

The following updated forms are requested to be submitted to CCLD by 05/27/2024:

• Updated Administrator Certificate
• Updated surety bond with expiration date
• LIC 308 Designation of Administrative Responsibility
• LIC500 Personnel Report
• LIC610E Emergency Disaster Plan
• Copy of current control property

Per the California Code of Regulations, Title 22, Division 6, Chapter 6, no deficiencies observed or cited. Report is reviewed with the administrator and a copy of the report is provided.
SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8865
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:
DATE: 05/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/20/2024
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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