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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601089
Report Date: 05/18/2021
Date Signed: 05/18/2021 03:53:21 PM

Document Has Been Signed on 05/18/2021 03:53 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
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:JAR HOMEFACILITY NUMBER:
415601089
ADMINISTRATOR:SORONGON, ESPERANZAFACILITY TYPE:
735
ADDRESS:2530 WENTWORTH DRIVETELEPHONE:
(650) 580-3896
CITY:SOUTH SAN FRANCISCOSTATE: CAZIP CODE:
94080
CAPACITY: 4CENSUS: 3DATE:
05/18/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:25 PM
MET WITH:Jevelyn ViernesTIME COMPLETED:
04:00 PM
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On May 18, 2021 Licensing Program Analyst (LPA) Chris Hopkins conducted an unannounced annual required inspection. LPA met with Licensee, Jevelyn Viernes, and stated the purpose of the visit.

LPA toured the indoor and outdoor premises of the facility. The indoor and outdoor passageways were free of obstruction. LPA observed the resident bathrooms, and they are equipped with non-skid mats and grab bars. Bathroom is sanitary and odorless. The hot water temperature was measured in residents master bathroom at 113 degrees Fahrenheit and 115 degrees Fahrenheit in hallway bathroom. 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. Sharps and toxic materials were observed locked in the kitchen cabinet and underneath the sink and inaccessible to residents. Food supply in kitchen and bin located in garage was observed with an adequate two day perishable and seven day non-perishable food supply. Carbon monoxide/ smoke detectors, and fire extinguisher were present throughout the facility. Centrally stored medication was locked in the medicine cart and inaccessible by residents. All medication was labeled and sorted by resident name.

Staff records were reviewed. Staff have criminal record and fingerprint clearances on file. 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.

No deficiencies observed today. Facility is operating in compliance with Title 22 regulations. This report was discussed with Licensee, Jevelyn Viernes, and a copy of this report was provided via email.
SUPERVISORS NAME: Julio Montes
LICENSING EVALUATOR NAME: Christopher Hopkins-Clarke
LICENSING EVALUATOR SIGNATURE: DATE: 05/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/18/2021
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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