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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601122
Report Date: 12/12/2023
Date Signed: 12/12/2023 03:41:10 PM


Document Has Been Signed on 12/12/2023 03:41 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:ARBOR HOUSEFACILITY NUMBER:
415601122
ADMINISTRATOR:ALPON, NILDAFACILITY TYPE:
740
ADDRESS:330 ARBOR DRIVETELEPHONE:
(510) 825-2287
CITY:SOUTH SAN FRANCISCOSTATE: CAZIP CODE:
94080
CAPACITY:4CENSUS: 3DATE:
12/12/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Nilda Alpon, Victoria Alejandro, Veronica RozarioTIME COMPLETED:
12:30 PM
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On 12/12/23, LPA Grace Donato made an unannounced annual visit to the facility. LPA met with Administrator Nilda Alpon, House Manager Veronica Rozario, Licensee Victoria Alejandro. LPA explained the purpose of the visit.

LPA toured the facility inside and outside including all of resident rooms, garage/laundry area, and kitchen area. LPA observed all residents to have left for Adult Day Program. While touring the facility it was observed that the room temperature was at 67 deg F. Hot water was also tested in the bathrooms and the temperature was 118 deg F. The facility is observed to be clean, odorless, and well maintained. Residents bedrooms were observed to be well organized and fully furnished with adequate lighting. Sharps and toxic materials were observed locked in a cabinet in the garage area and inaccessible to residents. Food supply was observed with an adequate two day perishable and seven day non-perishable. Carbon monoxide/ smoke detectors, and fire extinguisher were present throughout the facility. Facility has an updated log for emergency drill are done every month.

Three resident records and three staff records were reviewed. Resident’s PNI money was counted and all accounted for with proper log. Staff have criminal record and fingerprint clearances, First Aid/CPR certifications on file. Resident records were reviewed and were observed to be complete with documents such as Admission Agreements, Medical Assessments, and Needs and Service Plans. Centrally stored medication was locked in the medicine cart and inaccessible by residents. All medication was labeled and sorted by resident name. All medication logs are complete and updated.

LPA requested licensee to submit the following: LIC 500 Personnel Report, Liability Insurance.

No deficiencies are cited at this time. Report is reviewed with licensee and a copy is provided
SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8865
LICENSING EVALUATOR NAME: Grace DonatoTELEPHONE: (714) 293-8294
LICENSING EVALUATOR SIGNATURE:
DATE: 12/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/12/2023
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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