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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601107
Report Date: 08/04/2021
Date Signed: 08/04/2021 01:37:03 PM

Document Has Been Signed on 08/04/2021 01:37 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:BAY LEAF ELDERLY CARE HOME LLCFACILITY NUMBER:
415601107
ADMINISTRATOR:AVENA, MAYEANNE GUINOMMAFACILITY TYPE:
740
ADDRESS:1168 LYONS STREETTELEPHONE:
(650) 542-1692
CITY:REDWOOD CITYSTATE: CAZIP CODE:
94061
CAPACITY: 6CENSUS: 2DATE:
08/04/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Mayanne AvenaTIME COMPLETED:
02:00 PM
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On 08/04/2021 at 1100hrs Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced prelicensing inspection visit. LPA met with licensee/administrator Mayanne and explained purpose of today's inspection.

During today's inspection LPA toured the facility inside and out. This is a single story facility. Ambient temperature is observed as 72F. Fire lanes are clear on the outside of the facility. All resident bathrooms are inspected. Of the three, two do not have fully functioning faucets. Bathroom in main hallway does not produce hot water and knobs do not allow free flowing water. Bathroom in resident room faucet does not function at all but toilet and shower are operable. Main bathroom adjacent to living room is considered the main shower and bathroom. Faucet and shower functions appropriately. Water is tested at 125F at this time. 48hr fresh food supply is present. There are two freezers present as well and supplies are in place. Two week canned and dried goods are observed as in place. Resident bedrooms have all required furniture in place. Linens are observed as in place. Medications are locked and secured in office area. First aid kit is complete. Fire extinguishers are in place and fully charged. Fire alarms are hardwired in place and carbon monoxide detector is observed as plugged in adjacent to the kitchen. Cleaning solutions are observed as stored in hallway closet but is not locked. LPA did observe that the kitchen sink is full of dishes that require washing but this was corrected during today's inspection. Backyard had boxes of items that are in the process of being moved. Main dining table has paperwork and files that need organizing. Resident and staff files require organization. Facility floors do have areas with debris and foot prints from water near bathroom adjacent to living room. Areas in facility observed as well with dusty and spider webs. Resident files are reviewed as current but require updated admission agreements reflecting new facility. Fire drill log was not able to be reviewed. Facility does not handle cash resources of residents. Administrator certificate is current expiring on 8/5/2022.

The following updated forms are to be received by 08/20/2021:
LIC500
LIC308
LIC610E
Copy of current administrator certificate

Report is reviewed with administrator/licensee.
SUPERVISORS NAME: Julio Montes
LICENSING EVALUATOR NAME: Jaime Vado
LICENSING EVALUATOR SIGNATURE: DATE: 08/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/04/2021
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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