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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601121
Report Date: 11/15/2024
Date Signed: 11/15/2024 10:38:53 AM

Document Has Been Signed on 11/15/2024 10:38 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:CEDARHILL MANORFACILITY NUMBER:
415601121
ADMINISTRATOR/
DIRECTOR:
FORONDA-CAYABYAB, MARIE JAFACILITY TYPE:
735
ADDRESS:1117 EL CAMINO REAL #2TELEPHONE:
(650) 242-5211
CITY:BURLINGAMESTATE: CAZIP CODE:
94010
CAPACITY: 4CENSUS: 4DATE:
11/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Caregiver, Noel De LeonTIME VISIT/
INSPECTION COMPLETED:
10:45 AM
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On November 15, 2024, Licensing Program Analyst(LPA) Murial Han conducted an unannounced annual inspection. LPA met with caregivers Noel De Leon, Roberto Gozon and Ninfa Gozon and LPA explained the purpose of today's visit.

LPAs toured the facility inside and outside including the 2 shared bedrooms, 1 full- bathroom, kitchen, and common areas. The facility observed to clean, tidy and in good repair. Bedrooms were equipped with the required furniture for residents to use. Bathroom is equipped with grab bars, and nonskid mats. Facility temperature is comfortable. Hot water temperature in the bathroom and the kitchen were measured at 108-111 degrees F.

Central stored medication observed to be locked and inaccessible to residents in care.

Chemicals and sharp object reviewed and observed.

A review of (4) resident files was conducted and noted on the LIC 858.
A review of (3) staff files was conducted and noted on the LIC 859.

P & I were reviewed for 3 residents and observed to be adequate.

During the visit, there was no residents present at the facility and according to the facility staff, they were all attending day program.

No deficiency is cited today.

This report is reviewed and discussed with the facility staff and a copy is provided.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE: DATE: 11/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/15/2024
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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