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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601053
Report Date: 09/11/2024
Date Signed: 09/11/2024 12:10:25 PM

Document Has Been Signed on 09/11/2024 12:10 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:MONROJ HOMEFACILITY NUMBER:
415601053
ADMINISTRATOR/
DIRECTOR:
ROJAS, MONAFACILITY TYPE:
735
ADDRESS:451 3RD AVETELEPHONE:
(415) 279-5677
CITY:REDWOOD CITYSTATE: CAZIP CODE:
94063
CAPACITY: 4CENSUS: 4DATE:
09/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:20 AM
MET WITH:Administrator, Mona RojasTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
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On September 11, 2024, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced annual inspection. LPA met with Administrator, Mona Rojas and House Manager, Naina Bulaong and explained the purpose of the visit.

LPA toured the facility inside and outside including all of resident rooms, common areas & kitchen. The indoor and outdoor passageways were free of obstruction. No accessible bodies of water of fire safety hazards observed. LPA observed four resident bedrooms, all of which are private room. Bedrooms were observed to be clean, in good repair with all required furniture. Two full bathrooms were observed to be clean, equipped with liquid soap, paper towels, and non-skid mats.

Living room and dining room were observed to be free from tripping hazards. A comfortable temperature is maintained and lighting is sufficient for comfort. LPA toured kitchen and observed two day perishable and seven day non-perishables. Sharps, chemicals and medications were observed to be locked an inaccessible to clients. Water temperature throughout the facility measured at 110 degrees F. Carbon monoxide monitors are working properly. All fire extinguishers have been checked and current as of January 2024. Emergency fire and disaster drills are logged and conducted every three month. First aid kit was observed to be present. LPA toured the garage and observed washer and dryer.

LPA reviewed 4 resident records and 4 staff records. Resident records are updated, complete and signed. Staff records are complete and training logs are up to date. Medication review was done, and all medications are accounted for, and centrally stored medication records are updated. Facility has a facility van that gets serviced every 3-6 months.

No deficiencies are cited during the visit. Report is reviewed Administrator and a copy is provided.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE: DATE: 09/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/11/2024
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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