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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601122
Report Date: 12/03/2024
Date Signed: 12/03/2024 11:49:01 AM

Document Has Been Signed on 12/03/2024 11:49 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:ARBOR HOUSEFACILITY NUMBER:
415601122
ADMINISTRATOR/
DIRECTOR:
ALPON, NILDAFACILITY TYPE:
740
ADDRESS:330 ARBOR DRIVETELEPHONE:
(510) 825-2287
CITY:SOUTH SAN FRANCISCOSTATE: CAZIP CODE:
94080
CAPACITY: 4CENSUS: 4DATE:
12/03/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:Nilda AlponTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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On 12/3/23, 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 community outing. While touring the facility it was observed that the room temperature was at 69 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. 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.

Four resident records and four staff records were reviewed. Resident’s PNI money was counted and all accounted for. 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
SUPERVISORS NAME: Andrea Medlin
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE: DATE: 12/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/03/2024
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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