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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601115
Report Date: 03/01/2024
Date Signed: 03/01/2024 12:45:40 PM


Document Has Been Signed on 03/01/2024 12:45 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:GORDON MANORFACILITY NUMBER:
415601115
ADMINISTRATOR:GADDI, PORTIAFACILITY TYPE:
740
ADDRESS:1616 GORDON STREETTELEPHONE:
(650) 562-0555
CITY:REDWOOD CITYSTATE: CAZIP CODE:
94061
CAPACITY:82CENSUS: 67DATE:
03/01/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Administrator - Portia GaddiTIME COMPLETED:
12:50 PM
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On 03/01/2024 Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced 1 year annual inspection visit. LPA met with administrator Porita Gaddi and explained the purpose of today's visit.

LPA toured the facility inside and outside with the administrator. Emergency routes This is a single level facility. While touring the facility LPA tested the water in resident rooms. Water is tested at 111F. Resident rooms 102, 104, 109, 114, 120, and 301 are observed and are well maintained with the required furniture and lighting. Residents have an adequate amount of linens and incontinence supplies, incidental supplies, as well as PPE as needed stored in appropriate storage areas around the facility. Multiple fire extinguishers are stationed around the facility. LPA observed that they are charged and within the appropriate range. Tagged inspection is dated as 03/27/2023. Carbon monoxide detectors and smoke detector are present through out the facility. Facility is hardwired with smoke detectors and facility is fully equipped with sprinklers through out the facility. Two resident shower rooms are observed to be in good repair and contain the required non-skid floor mats and shower chairs for resident use. Incidental supplies such as shampoo, conditioner, and soap are available for resident use. LPA observed the kitchen of the facility. 7 day non-perishable food supply and 2 day fresh food supply is observed as in place. Kitchen appliances such as washing area, stove, and range are in working order. Prescribed food, modified, and diet plans are posted in the kitchen for staff reference.

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SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8865
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:
DATE: 03/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/01/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: GORDON MANOR
FACILITY NUMBER: 415601115
VISIT DATE: 03/01/2024
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Medications are stored and inaccessible in a locked medication room. Medications are stored and controlled medications are double locked in place. Medications are reviewed to be in place and accurately marked. Medication administration record is observed as current for clients reviewed including centrally stored medication log. First aid items are observed in medication room as well as plentiful and in place. Additional first aid kits are available outside of medication room. On site laundry is available and functioning per observations made.

5 staff records are reviewed. All staff has criminal record clearance and are associated with the facility. Based on record reviews, TB tests, training, CPR/First Aid cards, and personnel files are current. 5 resident records are checked and all are complete and updated. Disaster drill is last conducted on 11/16/2023 per records reviewed. Drills conducted vary on type of emergency based on record reviewed. Administrator is current and observed to be expiring on 04/23/2025.

The following updated items are requested to be sent to the Department by 03/08/2024:

• LIC610D Emergency Disaster Plan
• LIC 308 Designation of Administrative Responsibility
• LIC 500 Personnel Report
• Updated administrator certificate
• LIC9020 Client Roster
• Certificate of Liability Insurance
• Proof of control of property
• Surety bond with expiration date

Report is reviewed with Portia. No citations issued.
SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8865
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:

DATE: 03/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2024
LIC809 (FAS) - (06/04)
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