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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600992
Report Date: 02/12/2025
Date Signed: 02/12/2025 05:45:50 PM

Document Has Been Signed on 02/12/2025 05:45 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:DAYALU HOMEFACILITY NUMBER:
415600992
ADMINISTRATOR/
DIRECTOR:		REMY BANZUELAFACILITY TYPE:
735
ADDRESS:1590 GREENWOOD WAYTELEPHONE:
(650) 636-4762
CITY:SAN BRUNOSTATE: CAZIP CODE:
94066
CAPACITY: 4CENSUS: 3DATE:
02/12/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Administrator, Remy BanzuelaTIME VISIT/
INSPECTION COMPLETED:
12:15 PM
NARRATIVE
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On February 12, 2025 Licensing Program Analyst(LPA) Murial Han conducted an unannounced annual inspection. LPA was greeted by the administrator, Remy Banzuela and 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, and grab bars. Extra linen was present. LPA observed medications, toxins and sharps were locked and inaccessible to residents in care. 2 days of perishables and & 7 days non-perishable were observed to be present.

Facility is equipped with smoke detectors and carbon monoxide detectors. Fire extinguisher were last serviced in May 17, 2024. Fire drill records were reviewed.

A review of (3) resident files was conducted and noted on the LIC 858.
A review of (3) staff files was conducted and noted on the LIC 859.

LPAs reviewed P& I/ Case Resource Records for 2 residents to be adequate.

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

Based on observation, deficiency is cited under California Code of Regulations, Title, 22 cited on the LIC 809D. Failure to correct the deficiencies may result in civil penalties.

This report is reviewed and discussed with the administrator and the house manager. A copy of this report and the appeal rights were provided.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE: DATE: 02/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/12/2025
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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Document Has Been Signed on 02/12/2025 05:45 PM - It Cannot Be Edited


Created By: Murial Han On 02/12/2025 at 10:54 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: DAYALU HOME
FACILITY NUMBER: 415600992

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/12/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80069(c)(1)
Client Medical Assessments
(c) The medical assessment shall include the following: (1) The results of an examination for communicable tuberculosis and other contagious/infectious diseases.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as the Tuberculosis and other contagious/infectious diseases status were blank on 2 out of 3 resident's medical assessments which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/26/2025
Plan of Correction
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The administrator will provide a copy of the 2 out of the 3 resident's TB and other contagious/infectious disease results to CCL by 2/26/2025.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:April Cowan
LICENSING EVALUATOR NAME:Murial Han
LICENSING EVALUATOR SIGNATURE:
DATE: 02/12/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/12/2025


LIC809 (FAS) - (06/04)
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