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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601049
Report Date: 04/19/2024
Date Signed: 04/20/2024 12:14:55 AM


Document Has Been Signed on 04/20/2024 12:14 AM - 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:HEIRLOOM ROSE GARDENFACILITY NUMBER:
415601049
ADMINISTRATOR:SUNPAYCO, EDMUNDFACILITY TYPE:
740
ADDRESS:2305 TIPPERARY AVETELEPHONE:
(707) 315-9728
CITY:SOUTH SAN FRANCISCOSTATE: CAZIP CODE:
94080
CAPACITY:6CENSUS: 2DATE:
04/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:44 PM
MET WITH:Ed Sunpayco & Rose LoTIME COMPLETED:
04:00 PM
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On 4/19/24 LPA Grace Donato made an unannounced annual visit to the facility. LPA met with Administrator Ed Sunpayco & Co-Administrator Rose Lo. LPA explained the purpose of the visit.

LPA toured the facility inside and outside including all of resident rooms, living room and kitchen area. LPA observed residents watching tv in the 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 facility is observed to be clean, odorless, and well maintained. Residents bedrooms were observed to be well organized and fully furnished with adequate lighting. Resident bathrooms were observed to be in good repair equipped with grab bars and non-skid floor. Sharps and toxic materials were observed locked and inaccessible to residents. Food supply in was observed with an adequate two day perishable and seven day non-perishable food supply. Carbon monoxide monitor is working and fire extinguisher were present throughout the facility.

Two resident records and two staff records were reviewed. Staff have current First Aid/CPR certifications on file. Resident records were reviewed and were observed to be complete with documents such as Admission Agreements, Medical Assessments, and Needs and Service Plans.

Centrally stored medication was locked and inaccessible by residents. All medication was labeled and sorted by resident name. All medication logs are complete and updated.

Licensee to submit a copy of Control of Property, LIC 500, Liability Insurance.

No deficiencies are cited at this time. Report is reviewed and copy is provided.
SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8865
LICENSING EVALUATOR NAME: Grace DonatoTELEPHONE: (714) 293-8294
LICENSING EVALUATOR SIGNATURE:
DATE: 04/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/19/2024
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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