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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601121
Report Date: 11/18/2021
Date Signed: 11/18/2021 07:13:59 PM

Document Has Been Signed on 11/18/2021 07:13 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:CEDARHILL MANORFACILITY NUMBER:
415601121
ADMINISTRATOR:FORONDA-CAYABYAB, MARIE JAFACILITY TYPE:
735
ADDRESS:1117 EL CAMINO REAL #2TELEPHONE:
(510) 915-0629
CITY:BURLINGAMESTATE: CAZIP CODE:
94010
CAPACITY: 4CENSUS: DATE:
11/18/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Administratior, Marie Jan Foronda-CayabyabTIME COMPLETED:
03:15 PM
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On November 18, 2021, Licensing Program Analyst (LPA) Komal Charitra and Jaime Vado conducted an announced pre-licensing inspection visit in relation to an initial application. LPAs met with Administrator, Chris and Marie Cayabyab explained the purpose of today's visit. This facility is an all ambulatory facility with 2 shared bedrooms and 1 bathroom.

LPAs toured the facility and grounds with the administrators. No accessible bodies of water or fire safety hazards observed, LPA observed the centralized communal living room area. LPAs observed that the fire screen still needs to be installed. According to the Administrators the fire screen and the bedroom dressers will be put together on 11/22/2021.

LPAs observed the bathroom. The bathroom is equipped with hand-washing signs, liquid soap, paper towels, and non-skid mats. Water temperature in bathroom is measured at 120F. LPA advised Administrator to cover trash can with a lid. Bedroom 1 was observed to have two beds, 6FT apart. Dressers to be installed. Bedroom 2, beds will be rearranged to where the beds will be 6ft apart. Night stands and night lights are present in both rooms. Dressers will be installed and placed in the rooms Monday. Extra linen and first aid kit was observed to be present.

LPAs observed the carbon monoxide and fire alarms present. Emergency night lights were present in the hallway. Kitchen area was toured and there were two locked cabinets for sharps and medication. Laundry room was observed in a locked basement area for staff only. Washer and dryer are observed as functioning.

LPAs advised to post COVID-19 signage throughout the facility. LTCO posting needs to be posted..

Report was reviewed with the Administrators and the a copy will be provided.
SUPERVISORS NAME: Julio Montes
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE: DATE: 11/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/18/2021
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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