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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601115
Report Date: 02/24/2022
Date Signed: 02/24/2022 11:58:52 AM


Document Has Been Signed on 02/24/2022 11:58 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:GORDON MANORFACILITY NUMBER:
415601115
ADMINISTRATOR:GADDI, PORTIAFACILITY TYPE:
740
ADDRESS:1616 GORDON STREETTELEPHONE:
(650) 562-0555
CITY:REDWOOD CITYSTATE: CAZIP CODE:
94061
CAPACITY:82CENSUS: 69DATE:
02/24/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Portia GaddiTIME COMPLETED:
12:00 PM
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On this day at 1015hrs, Licensing Program Analysts (LPA) Jaime Vad conducted an unannounced pre-licensing inspection visit. LPA met with administrator Portia Gaddi and explained purpose of today's inspection

LPA toured the facility's building and grounds. Entire facility is hardwired with smoke detectors, fire sprinkler system, and fire panel. Fire panel last inspected on 2/15/2022 and had passed all inspections conducted by Bay Alarm. Carbon Monoxide detector is observed and tested as fully functional. Fire extinguishers are last inspected on 1/12/2021 but all observed extinguishers are fully charged and available for use. Outside rear of facility contains a large backyard area for residents and family to visit. There are no fountains or bodies of water present. Side entrance gate is closed and not locked. Residents do not have access to this gate or the adjacent side street of the facility. Facility is equipped with Wander Guard system. Inspected rooms contain pull cords and button call system for resident use in bedroom and bathrooms.

LPA inspected the kitchen and dining room areas. Dining room area is observed as clean and in order. Range and stove are clean and operable. Food preparation areas observed as organized and clean. Modified diet plans for residents are posted for staff reference. Ansul fire suppression system last inspected on 9/2/2021. Range venting hood is observed as clean. Both fresh food and frozen food supplies are inspected and observed as in place. Dry goods/emergency food supplies are in place. Kitchen receives deliveries of these good via Sysco regularly.

LPA observed the central medication room. Facility does not use a medication cart. A lock pad is observed for access to the medication room and at time of inspection LPA observed two staff in this room. Refrigerator for medications is in place. Narcotics are locked and secured. Resident records are in place and observed in binders located within. Complete first aid kit is located in the medication room. Through out the facility there are additional first aid kits available. LPA observed the facility spare linens as in place and plentiful. Facility's PPE supply is observed as in place and ready for use. Cleaning supply closet is observed as locked and secured. Cleaning cart is used but locked and secured when not in use. Laundry room is observed as fully operational.

LPA observed resident rooms observed are occupied and contain all the required furniture for resident use. Ambient room temperatures are comfortable through out the facility. Pull cord system and push button system is observed. Water temperatures were taken are within range. Room 225 water temp read at 110F, Room 208 water temp read at 120F, Room 121 water temp read at 117F, Room 115 water temp read at 117F.

Facility is in compliance with Title 22 regulations. No citations are issued.

Report is reviewed with administrator.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:
DATE: 02/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/24/2022
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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