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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601105
Report Date: 03/11/2021
Date Signed: 03/11/2021 02:53:46 PM

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:FAMILY AFFAIR CARE HOMEFACILITY NUMBER:
415601105
ADMINISTRATOR:LESLIE, HUI C.FACILITY TYPE:
740
ADDRESS:3100 COLLEGE DR.TELEPHONE:
(650) 871-5095
CITY:SAN BRUNOSTATE: CAZIP CODE:
94066
CAPACITY:6CENSUS: DATE:
03/11/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Hui Leslie, AdministratorTIME COMPLETED:
02:00 PM
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On March 11, 2020 at 1:10 PM, LPA Raygoza conducted an announced virtual Prelicensing inspection. LPA Raygoza and Administrator, Hui conducted a facetime tour of premises.

LPA Raygoza observed a deck on left side with table, chairs and bench just before entrance to facility. LPA toured the indoor and outdoor premises with the Administrator. Two shared resident's bedrooms were viewed and bathroom's were observed to have grab bars. The main resident's bathroom has a shower with nonskid floor and grab bars. Two private bedrooms share a bathroom with grab bars. There are four residents' bathrooms on premises with one main bathroom with shower. All residents' bedrooms are adequately furnished and have sufficient lighting. Hot water was tested and measured at 115 degrees Fahrenheit in resident's bathroom. The outdoor passageways were clear and free of obstruction. All CCL forms are placed visibly in hallway.

In Kitchen, two day perishable and seven day non-perishable food supplies were inspected and are sufficient for four residents. Knives and kitchen tools are kept inaccessible to residents and kept in a locked drawer. LPA observed medication in a locked closet. In Linen closet, both linen and paper products were stocked and in ample supply. Chemicals are kept locked in a cabinet in garage. A Freezer for food and another refrigerator for food were observed in garage. LPA viewed First aid kit as complete with bandages, tweezers, scissors, and thermometer. First Aid kit in a basket in kitchen readily accessible. Two Fire extinguisher and sprinkler system throughout facility premises. Smoke detectors and carbon monoxide detectors were present at the facility. Facility has operable alarm. Emergency lantern and flashlight present in facility. According to Administrator, Hui, the Fire Drills are conducted quarterly with last drill conducted in November, 2020.

As a result of inspection today, the physical plant is approved for licensing pending the completion of all documentation and the approval of the Centralized Application Unit (CAU). This report was discussed and a copy of this report given to facility Administrator, Hui whose signature on this form confirm receipts of these documents.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Bertha RaygozaTELEPHONE: (650) 266-8833
LICENSING EVALUATOR SIGNATURE:

DATE: 03/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2021
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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