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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601107
Report Date: 10/14/2024
Date Signed: 10/14/2024 03:08:39 PM

Document Has Been Signed on 10/14/2024 03:08 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:BAY LEAF ELDERLY CARE HOME LLCFACILITY NUMBER:
415601107
ADMINISTRATOR/
DIRECTOR:
AVENA, MAYEANNE GUINOMMAFACILITY TYPE:
740
ADDRESS:1168 LYONS STREETTELEPHONE:
(650) 542-1692
CITY:REDWOOD CITYSTATE: CAZIP CODE:
94061
CAPACITY: 6CENSUS: 4DATE:
10/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:40 AM
MET WITH:Mayeanne Guinomma, Licensee/Administrator and Cassandra Rose, Caregiver TIME VISIT/
INSPECTION COMPLETED:
03:15 PM
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On October 14, 2024, Licensing Program Analyst(LPA) John Calandra arrived at the facility at 8:40 AM to conduct the unannounced Annual 1-year required inspection. LPA Calandra was greeted by Mayeanne Guinomma, Licensee/Administrator and Cassandra Rose, Caregiver and explained the purpose of the visit.

LPA Calandra toured the physical plant. This is a 1-story building with 5 bedrooms, 3 bathrooms, backyard, kitchen, living room, dining room, and office. All bedrooms had the required furniture and sufficient lighting. Hot water temperature was measured within the required 105-120 degrees Fahrenheit. No accessible bodies of water or hazards were observed in the front or back yards. Night lights were observed in the hallways. The facility's Smoke Alarms and Carbon Monoxide detector were observed to be in working order. The facility's first aid kit was observed to have all required items. The facility had the required 7 days of non-perishables and 2 days of perishables; No food was expired.

All sharp objects, medications, poisons, and cleaning supplies were locked up and in-accessible to persons in care.

LPA reviewed 4 resident records and 3 staff records. All were observed to be complete.

LPA interviewed 3 residents.

LPA requested the following documents be sent to the Regional Office/Licensing by 10/21/2024:
-Current lease agreement
-Current LIC 500
-Current Liability Insurance

A review of resident medications showed that all medications matched the Centrally Stored Medication Records kept at the facility.

No deficiencies were cited during today's visit.

This report was reviewed with Mayeanne Guinomma, Licensee/Administrator and Cassandra Rose, Caregiver and a copy of the report was left at the facility.
SUPERVISORS NAME: Andrea Medlin
LICENSING EVALUATOR NAME: John Calandra
LICENSING EVALUATOR SIGNATURE: DATE: 10/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/14/2024
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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