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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601131
Report Date: 09/27/2022
Date Signed: 09/27/2022 11:18:20 AM

Document Has Been Signed on 09/27/2022 11:18 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
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:JLF CANYON HOUSEFACILITY NUMBER:
415601131
ADMINISTRATOR:GADDI, PORTIAFACILITY TYPE:
740
ADDRESS:817 CANYON RDTELEPHONE:
(650) 299-1057
CITY:REDWOOD CITYSTATE: CAZIP CODE:
94062
CAPACITY: 6CENSUS: 0DATE:
09/27/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Alisa TuTIME COMPLETED:
11:15 AM
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On this day Licensing Program Analyst (LPA) Jaime Vado conducted an announced pre-licensing inspection visit. LPA met with COO Alisa Tu and explained purpose of today's inspection.

LPA toured the facility's building and grounds. There are no resident or staff present as this time. The facility does not have any residents in place. Water heater and laundry room are located in the garage. Laundry appliances are functional. The garage also contains a large storage room. All utilities are connected and functioning through out the facility. PPE storage will be in garage. Toxics as well will be stored and locked in the garage. Egress routes are clear and easily definable and labeled with exit signs and egress route maps. COVID postings are in place on the main door to the facility and through out the building. Hand washing signs are in place in all bathrooms.

All fire prevention systems such as sprinklers, smoke detectors, carbon monoxide detectors, fire extinguishers, and fire control panel have been inspected and approved. Extinguishers are observed as charged and ready to be used. Inspected on 8/10/2022.

LPA inspected the kitchen and dining room area. Dining room area is observed as clean and in order. Chairs are in place. Both fresh food and frozen food supplies will be put in place prior to the facility accepting its first resident(s). Dry goods/emergency food supplies will be stored in the garage. LPA observed an office in the hallway leading to the garage and the plan for the licensee is to have the medications stored in this office in a lockable cabinet First aid kits will be located in the kitchen, office, and garage. Emergency lighting and supplies will also be stored in the kitchen, office, and garage. There is a fire place in the facility but it does not function according to Alisa. The fire place is gated.

LPA observed resident rooms and they contain the required furniture for their use. LPA observed all six resident rooms. Each room is connected to a shared half bathroom. Water temperature is taken in two of the bathrooms measuring 105F. There is a large full bathroom near the front of the facility that contains a large shower for resident use. Non-slip mats are present and grab bars.

Facility is clean and in good repair based on observations made today. Facility is in compliance with Title 22 regulations. No citations are issued. LPA is recommending licensure of the facility.

Component III is conducted and report is reviewed with COO Alisa Tu.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Jaime Vado
LICENSING EVALUATOR SIGNATURE: DATE: 09/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/27/2022
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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