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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600989
Report Date: 01/29/2024
Date Signed: 01/29/2024 05:13:58 PM

Document Has Been Signed on 01/29/2024 05:13 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:OAKWOOD HOMEFACILITY NUMBER:
415600989
ADMINISTRATOR:MADONNA VALENCIAFACILITY TYPE:
734
ADDRESS:313 EAST OAKWOOD BLVDTELEPHONE:
(650) 995-7837
CITY:REDWOOD CITYSTATE: CAZIP CODE:
94061
CAPACITY: 4CENSUS: 3DATE:
01/29/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Anna Fernandez and Claire AscalonTIME COMPLETED:
05:30 PM
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LPA Audrey Jeung toured facility and grounds, including detached garage. All passageways are unobstructed and there are no accessible bodies of water or safety hazards observed. Medications and sharps are stored appropriately and inaccessible to clients. Hot water temperature is tested at 107 degrees in main shower/bathroom. Food supply--consisting of liquid formula for 2 clients and regular food for one--and first-aid kit are inspected, and hygiene items for general use are maintained, as well as PPE.
All residents have Hill-Rom hospital beds and all utilize full bed rails; facility maintains approved waiver for use of full bed rails.
Disaster drills are documented and are conducted regularly; the most recent one was done in December 2023. Medications are recorded on Centrally Stored Medications Records. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed, and current first-aid training for caregivers is current. Madonna Valencia and Claire Ascalon are certified ARF administrators (x 10/25 and 6/24) that oversee facility operations for this Adult Residential Facility for Persons with Special Health Care Needs. Facility employs LVNs and RNs around the clock to administer nutrition, hydration and medications; professional licenses for LVNs and RNs on premises are verified as current.
There is no staff room, as facility employs awake night staff.

The following updated forms are given to LPA today:
• LIC 500 Personnel Report
• LIC 610 Emergency Disaster Plan
• LIC 308 Designation of Facility Responsibility

Updated Administrative Organization (LIC309) and proof of current surety bonding are requested to be submitted to CCLD by 2/12/24.

No deficiencies of the California Code of Regulations, Title 22, are observed. See Advisory Notes--4 pages.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Audrey Jeung
LICENSING EVALUATOR SIGNATURE: DATE: 01/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/29/2024
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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