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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601004
Report Date: 12/10/2024
Date Signed: 12/10/2024 01:42:24 PM

Document Has Been Signed on 12/10/2024 01:42 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:CLAIRESPIE HOME ARFPSHNFACILITY NUMBER:
415601004
ADMINISTRATOR/
DIRECTOR:
CLAIRE ASCALONFACILITY TYPE:
734
ADDRESS:1505 MADDUX DRIVETELEPHONE:
(650) 260-2659
CITY:REDWOOD CITYSTATE: CAZIP CODE:
94061
CAPACITY: 4CENSUS: 3DATE:
12/10/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH:Noel BarilTIME VISIT/
INSPECTION COMPLETED:
01:45 PM
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LPA Audrey Jeung, toured facility and grounds of this Adult Residential Facility for Persons with Special Healthcare Needs. There are 4 private client bedrooms, all equipped with overhead electronic hoyer lift systems. There are no accessible bodies of water nor fire safety hazards observed, and passageways are unobstructed. All residents use oxygen, and appropriate signs are posted. All residents have gastrostomy tubes, and one client eats by mouth. Carbon monoxide detector is tested and operable. A comfortable temperature is maintained and lighting appears adequate for safety. Hot water temperature is tested at 108 degrees in client bathroom. Food supply--including liquid formula for 2 clients--and first-aid kit are inspected, and PPE and hygiene items for general use are maintained. Client files are reviewed, and medications are recorded on Centrally Stored Medications Records. Disaster drills are documented and performed every other month. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed. Claire Ascalon maintains ARF certification (x 6/26). There is no staff room, as facility employs awake night staff.

The following updated licensing forms are requested to be sent to CCLD BY 12/17/24:
- Administrative Organization (LIC 309)
- Designation of Administrative Responsibility (LIC308)
- Personnel Report (LIC 500)

Updated Emergency Disaster Plan (LIC610D) is given to LPA today.


No deficiencies of the California Code of Regulations, Title 22, are cited. Facility is operating in substantial compliance.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Audrey Jeung
LICENSING EVALUATOR SIGNATURE: DATE: 12/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/10/2024
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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