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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601026
Report Date: 12/02/2024
Date Signed: 12/02/2024 04:38:58 PM

Document Has Been Signed on 12/02/2024 04:38 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:EARLY HORIZONS HOME CAREFACILITY NUMBER:
415601026
ADMINISTRATOR/
DIRECTOR:
ROGAYAN, YOLANDAFACILITY TYPE:
740
ADDRESS:2800 SHANNON DRTELEPHONE:
(650) 255-5418
CITY:S SAN FRANCISCOSTATE: CAZIP CODE:
94080
CAPACITY: 6CENSUS: 3DATE:
12/02/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Irene MehtaTIME VISIT/
INSPECTION COMPLETED:
04:45 PM
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On 12/02/2024 LPA Grace Donato made an unannounced annual visit to the facility. LPA met with Co-Administrator Irene Mehta. LPA explained the purpose of the visit.

LPA toured the facility inside and outside including all of resident rooms, common areas, kitchen area & garage. The indoor and outdoor passageways were free of obstruction. Facility has 2 storage sheds at the back which was checked by the LPA. LPA observed some residents resting in their bedrooms and living room. While touring the facility it was observed that the room temperature was at 70 deg F. Hot water was also tested in the bathrooms and the temperature was 110 deg F. The residents have adequate amount of linens and incontinence care items. All personal belongings are intact. Carbon monoxide monitors are working properly. Resident bedrooms are observed to be in good repair. Bathroom is equipped with grab bars non-skid floors. LPA checked the food supply and there is adequate amount of food, 2 days for perishables and & 7 days non-perishable. Emergency drills are logged and done every quarter.

Three resident records and two staff records were reviewed. Resident records are updated, complete and signed. Staff records are complete, with training logs that have met the basic requirement. Facility has a certified administrator on site with complete certification and training requirements.

Medication review was done, and all medications are accounted for, and centrally stored medication records are updated.

No deficiencies are cited at this time. Report is reviewed with Administrator and a copy is provided.
SUPERVISORS NAME: Andrea Medlin
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE: DATE: 12/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/02/2024
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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