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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601107
Report Date: 09/16/2021
Date Signed: 09/16/2021 11:20:32 AM

Document Has Been Signed on 09/16/2021 11:20 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: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:
09/16/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Mayanne AvenaTIME COMPLETED:
11:15 AM
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On 09/16/2021 at 0900hrs Licensing Program Analyst (LPA) Jaime Vado and Komal Charitra conducted an unannounced prelicensing inspection visit. LPA met with licensee/administrator Mayanne and explained purpose of today's inspection.

LPAs made observations within the facility. LPAs inspected three facility bathrooms and all are in good condition. Faucets operate appropriately. Water temperatures are taken at all three faucets. Main bathroom located adjacent to living room water temp is 112F. Bathroom in hallway faucet temperature is measured at 107F. Bathroom water temp in resident room is measured at 107F. Facility floors are observed as clean and with no debris. Facility fire drill log is observed as current. Last fire drill was conducted on 08/14/21. Backyard is observed as clear of boxes that were previously there on prior visit. Cleaning solutions are observed in locked hallway closet. Facility PPE is present. Facility food supplies are in place. Kitchen is observed as clean.

As a result of inspection today, the physical plan of this home is in substantial compliance with the Regulation requirements for a Residential Care Home for the Elderly today, and is pending the completion of all documentation and the final approval of the Centralized Application Unit (CAU).

Component three is conducted today with licensee.
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Jaime Vado
LICENSING EVALUATOR SIGNATURE: DATE: 09/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/16/2021
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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