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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601038
Report Date: 08/08/2023
Date Signed: 08/08/2023 01:46:08 PM


Document Has Been Signed on 08/08/2023 01:46 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:SUNVILL BOARD AND CARE IIFACILITY NUMBER:
415601038
ADMINISTRATOR:VILLARAZA, LOUELFACILITY TYPE:
740
ADDRESS:771 CAMARITAS AVETELEPHONE:
(650) 278-0008
CITY:SOUTH SAN FRANCISCOSTATE: CAZIP CODE:
94080
CAPACITY:6CENSUS: 5DATE:
08/08/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:25 PM
MET WITH:Louel Villaraza Jr.TIME COMPLETED:
01:50 PM
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On 8/8/2023, Licensing Program Analyst (LPA) Grace Donato conducted an unannounced case management visit. LPA met with caregiver, Louel Villaraza Jr. LPA explained the purpose of the visit.

On 8/3/23, facility submitted an incident report regarding a resident (R1) having bruise on chin area which was pinched by a caregiver (S1) before leaving the facility.

Based on interviews, S1 is from the hospice agency and not employed by facility. S1 is not allowed to enter the facility anymore. Current staff has been re-trained regarding personal rights of residents.

No deficiency is cited today.

Report was discussed and a copy of this report is provided.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Grace DonatoTELEPHONE: (714) 293-8294
LICENSING EVALUATOR SIGNATURE:
DATE: 08/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/08/2023
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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