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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601131
Report Date: 10/07/2024
Date Signed: 10/07/2024 12:39:28 PM

Document Has Been Signed on 10/07/2024 12:39 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:CANYON PLACEFACILITY NUMBER:
415601131
ADMINISTRATOR/
DIRECTOR:
GADDI, PORTIAFACILITY TYPE:
740
ADDRESS:817 CANYON RDTELEPHONE:
(650) 299-1057
CITY:REDWOOD CITYSTATE: CAZIP CODE:
94062
CAPACITY: 6CENSUS: 6DATE:
10/07/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:Mayvelle Reyes, Caregiver/Lead Staff and Portia Gaddi, AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:45 PM
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On October 7, 2024, Licensing Program Analyst(LPA) John Calandra arrived at the facility at 8:45 AM to conduct the Annual 1-year required inspection. LPA Calandra was greeted by Mayvelle Reyes, Caregiver/Lead Staff and explained the purpose of the visit. Portia Gaddi, Administrator arrived later during the visit.

LPA Calandra toured the physical plant. This is a 1-story building with 6 bedrooms, 4 bathrooms, office, garage, backyard, kitchen/dining room, and lounge. No accessible bodies of water or hazards were observed in the hallways or backyard. The facility was maintained at a comfortable temperature of 70 degrees Fahrenheit. Water temperature was measured within the required 105-120 degrees Fahrenheit. The facility's fire alarms and Carbon Monoxide detectors were observed to be in working order. Per interview with Administrator, Portia Gaddi, the facility fire alarms and carbon monoxide detectors are integrated and connected directly to the Redwood City fire department via Bay Alarm. All bedrooms had the required furniture and sufficient lighting. The facility had the required 7 days of non-perishables and 2 days of perishables on site. No food was expired. The facility's first aid kit had the required items.

All sharp objects, poisons, soaps, and detergents were observed to be locked up and in-accessible to persons in care.

LPA Calandra requested and received a copy of the facility's Liability insurance.

LPA Calandra reviewed 6 resident files and 5 staff files. All were observed to be complete.

LPA reviewed Medications which matched the Centrally Stored Medication Records(CSMR) kept at the facility.

No deficiencies were cited during today's visit. An exit interview was conducted. This report was reviewed with Portia Gaddi, Administrator and a copy of the report left at the facility.
SUPERVISORS NAME: Andrea Medlin
LICENSING EVALUATOR NAME: John Calandra
LICENSING EVALUATOR SIGNATURE: DATE: 10/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/07/2024
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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