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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601086
Report Date: 08/12/2021
Date Signed: 09/05/2023 11:01:29 AM

Document Has Been Signed on 09/05/2023 11:01 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
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:SEQUOIA HOMEFACILITY NUMBER:
415601086
ADMINISTRATOR:FUJII, ROGERFACILITY TYPE:
735
ADDRESS:1499 SEQUOIA AVENUETELEPHONE:
(415) 279-3128
CITY:SAN BRUNOSTATE: CAZIP CODE:
94066
CAPACITY: 4CENSUS: 3DATE:
08/12/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Jayson HernandezTIME COMPLETED:
12:15 PM
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***THIS DOCUMENT WAS CREATED IN ERROR. THIS REPORT DOES NOT APPLY TO THIS FACILITY LOCATION***

On 08/12/2021, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced annual inspection visit focused on infection control. LPA met with facility administrator Jayson Hernandez and explained purpose of today's visit.

LPA the toured facility's building and grounds. No accessible bodies of water or fire safety hazards observed. Infection control practices are reviewed: entry procedures, staff training and policies, resident monitoring, containment strategies, environmental preparation and cleaning. PPE supply is observed as in place. Off site additional PPE is in storage for facility use. Medications, toxins and sharps are stored appropriately and inaccessible to clients. Facility ambient temperature is comfortable. Facility lighting is sufficient for residents and staff safety. Toilet and bathing facilities are equipped properly. Liquid soap is available. Clients have access to hand sanitizers as well. First-aid kit is inspected and complete. A Disaster and Mass Casualty Plan is posted. There are 3 clients present and staff are present providing one on one supervision. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed as current. Staff first aid cards reviewed are current. Administrator certificate is current expiring 04/14/2022

The following updated forms are requested to be submitted to CCLD by 08/18/2021:

• LIC 308 Designation of Administrative Responsibility
• LIC 400 Affidavit Regarding Client Cash Resources
• LIC 500 Personnel Report
• LIC 610D Emergency Disaster Plan

No deficiencies cited during today's inspection.

Report is reviewed with Administrator Jayson Hernandez.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Jaime Vado
LICENSING EVALUATOR SIGNATURE: DATE: 08/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/12/2021
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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