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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600992
Report Date: 01/25/2024
Date Signed: 01/25/2024 06:24:55 PM

Document Has Been Signed on 01/25/2024 06:24 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:DAYALU HOMEFACILITY NUMBER:
415600992
ADMINISTRATOR:REMY BANZUELAFACILITY TYPE:
735
ADDRESS:1590 GREENWOOD WAYTELEPHONE:
(650) 636-4762
CITY:SAN BRUNOSTATE: CAZIP CODE:
94066
CAPACITY: 4CENSUS: 4DATE:
01/25/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:House Manager, Rem PauleTIME COMPLETED:
11:25 AM
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On 1/25/2024, Licensing Program Analyst(LPA) Murial Han conducted an unannounced annual inspection. LPA was greeted by the house manager, Rem Paule. LPA explained the purpose of the visit.

LPA toured facility and grounds. No accessible bodies of water or fire safety hazards observed. LPA toured the facility inside and outside including all of resident rooms, common areas, and kitchen area. The indoor and outdoor passageways were free of obstruction. Facility was overall clean and odor-free. Comfortable temperature is maintained and lighting is sufficient for comfort.

LPA observed four private resident rooms. Rooms were spacious and included all required furnishings. Two full bathrooms were observed to be clean; equipped with paper towels, soap, grab bars, and non-skid mats. Extra linen was present. LPA medications, toxins and sharps were observed to be locked. 2 days for perishables and & 7 days non-perishable were observed to be present. Egress delayed door alarms were observed to be in good repair.

Facility is equipped with smoke detectors and carbon monoxide detectors. Fire extinguisher were last serviced in May 17, 2023. Fire drill records were reviewed.

LPA reviewed 4 resident records and all of them contained Admission Agreement, Medical Assessment- LIC 602 (Physician Order), Appraisal Needs and Service Plan, Resident Identification information, Pre-Placement Appraisals, GGRC/IPP, etc.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE: DATE: 01/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/25/2024
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
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: DAYALU HOME
FACILITY NUMBER: 415600992
VISIT DATE: 01/25/2024
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LPA reviewed 3 staff files and all of them contained Personnel Records, Training Records, Health Screening Records, Job Description, Abuse Statement, First Aid/CPR, Criminal Record Statement, Criminal Background Clearance, etc.

LPAs reviewed P& I/ Case Resource Records for 3 residents to be adequate.

During today's inspection, there are no residents present as all of them are attending the day program.

No deficiency cited today.

This report is reviewed and discussed with house manager. A copy is provided.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:

DATE: 01/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2024
LIC809 (FAS) - (06/04)
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