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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600995
Report Date: 06/14/2019
Date Signed: 06/14/2019 09:16:29 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:ATHERTON GARDENSFACILITY NUMBER:
415600995
ADMINISTRATOR:HOVORKA, KIMBERLYFACILITY TYPE:
740
ADDRESS:471 SANTA CLARA AVETELEPHONE:
(650) 364-0233
CITY:REDWOOD CITYSTATE: CAZIP CODE:
94061
CAPACITY:6CENSUS: 0DATE:
06/14/2019
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Kimberly C HovorkaTIME COMPLETED:
09:30 AM
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Licensing program Analyst (LPA) Diego Escobar conducted an unannounced required one-year inspection visit on 6/14/19 at 8:15AM. During the visit, LPA met with, Kimberly Hovorka, Licensee, and explained the purpose of the visit. LPA toured the facility with Kimberly at 8:30AM. No residents are residing at the facility.

All outdoor and indoor passageway are free and clear of obstruction. Facility is maintained at a temperature of 69 degrees F. A pool was observed during todays visit. Licensee stated that the residents would not have access the pool. LPA observed two self latching gates that lead to the pool. Pool perimeter is enclosed with a screen mesh in approximate 6.5 feet tall. LPA observed at least one week of nonperishable. Toxic chemicals are stored away in a locked cabinet in the garage. Centrally stored medications are locked in a cabinet in the kitchen. Each room is equipped with two beds, working lights, dressers, and a night stand for each resident. Facility has functioning smoke detectors. LPA observed Kimberly test the carbon monoxide detector in the kitchen. Licensee stated there are no firearms or ammunition at the facility. Fire extinguisher in the kitchen is full. LPA inspected all resident rooms and confirmed there were no residents in the facility. LPA observed no resident belongings. Licensee stated that there has been no residents since the facility opened. Licensee has a current administrator certificate with the expiration date of 2/3/21.

No deficiencies were cited during today's inspection. Report reviewed with licensee.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Diego EscobarTELEPHONE: (650) 676-0051
LICENSING EVALUATOR SIGNATURE:

DATE: 06/14/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2019
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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