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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601067
Report Date: 04/15/2024
Date Signed: 04/15/2024 11:36:55 AM

Document Has Been Signed on 04/15/2024 11:36 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:ISPOT DAY PROGRAMFACILITY NUMBER:
415601067
ADMINISTRATOR/
DIRECTOR:		GOMINTONG, NELSONFACILITY TYPE:
775
ADDRESS:198 LOS BANOS AVETELEPHONE:
(650) 200-8055
CITY:DALY CITYSTATE: CAZIP CODE:
94014
CAPACITY: 16CENSUS: 4DATE:
04/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Administrator - Nelson GamintongTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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On 04/14/2024, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced required - 1 year inspection. LPA met with administrator Nelson Gamintong and explained the purpose of today's visit.

LPA was allowed entry into the facility that is licensed to serve 16 ambulatory clients of which 6 maybe non-ambulatory. Annual Fees are not current but discussed with administrator. During today's visit the administrator paid the annual fees and provided evidence of doing so. There are no clients present during today's inspection as they are out on a community outing. The physical plant was toured inside and outside to ensure the safety of the clients. The facility does not prepare food, does not store medications for the clients, and does not handle any client cash. Facility provides only snacks and water as observed. Facility also does have an emergency food supply and dry goods as a precaution. LPA observed the facility conducted fire drills on 7/14/23. There is a pull alarm fire system, fire extinguisher(s), smoke and carbon monoxide detectors, central heating and air in the facility. The temperature inside the facility was comfortable and warm. There are two bathrooms on site. One is equipped with a shower and the other is a half bathroom at the rear of the facility. Shower is equipped with non-skid flooring. Water temperature is tested at 105F. The first aid kit was observed containing at least the following: a current edition of a first aid manual approved by the American Red Cross, the American Medical Association or a state or federal health agency, sterile first aid dressings, bandages or roller bandages, adhesive tape, scissors, tweezers, thermometers, and antiseptic solution. Earthquake drill last conducted March 28, 2024. Administrator certificate is current expiring 11/2024. LPA reviewed 2 staff files and 2 client files on site. All are current and contain required documents.

The following updated items are being requested to be submitted to the department by 04/22/2024:

• LIC610D Emergency Disaster Plan
• LIC 308 Designation of Administrative Responsibility
• LIC 500 Personnel Report
• Updated administrator certificate
• LIC9020 Client Roster
• Certificate of Liability Insurance
• Evidence of lease agreement

No citations issued. Report is reviewed with Nelson.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Jaime Vado
LICENSING EVALUATOR SIGNATURE: DATE: 04/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/15/2024
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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