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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601147
Report Date: 01/17/2023
Date Signed: 01/17/2023 11:34:41 AM

Document Has Been Signed on 01/17/2023 11:34 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:WALLY'S PLACE, MATEO LODGE, INC.FACILITY NUMBER:
415601147
ADMINISTRATOR:BARTOLOME, KRISFACILITY TYPE:
735
ADDRESS:695 FIFTH AVE.TELEPHONE:
(650) 568-9008
CITY:REDWOOD CITYSTATE: CAZIP CODE:
94063
CAPACITY: 13CENSUS: 0DATE:
01/17/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Administrator, Kris BartolomeTIME COMPLETED:
11:45 AM
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On January 17, 2023, Licensing Program Analyst (LPA) Komal Charitra conducted an announced Pre-Licensing visit. LPA met with Administrator, Kris Bartolome and CEO, Ian Adamson, and explained the purpose of the visit. Upon arrival, LPA observed the COVID-19 signage posted on the front entrance.

LPA toured the facility and grounds. No accessible bodies of water or fire safety hazards observed. This is a two story facility with eight client bedrooms, two office rooms and three bathrooms. LPA toured the facility with the Administrator and CEO and observed three of the client rooms to be private rooms and the other five client rooms to be shared rooms with beds 6ft apart. All bedrooms contained the required furniture and lighting requirements per CCLD regulations. LPA observed the 30-day PPE supply located on the 2nd floor of the facility. Locked medication cabinet is observed to be located on the second floor office room.

LPA inspected the kitchen and dining room area. Dining room area is observed to be clean and in order. Chairs are in place. Both fresh food and frozen food supplies are inspected and observed as in place in the kitchen. Dry goods/emergency food supplies are present. Toxins, chemicals, and sharps were locked and stored appropriately and inaccessible to clients. All required facility postings are posted in the dining room bulletin board.

Bathrooms were observed to be equipped with paper towels, hand-washing signs, liquid soap, trash cans with fitted lids, and non-skid mats. Water temperature throughout the facility was measured between 117-118 degrees F. Facility was maintained at a comfortable temperature. All fire prevention systems such as, smoke detectors, carbon monoxide detectors, fire extinguishers, and fire control panel have been inspected and approved as of 12/8/2022. Fire alarms, smoke detectors, and carbon monoxide systems are operating properly. COVID-19 signs were posted throughout the facility. First aid kit was observed to be located on the first and second floor office rooms. Extra linen was present. LPA observed the outdoor patio to be clean and clear from any tripping hazards.

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 Administrator and CEO and a copy is provided.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE: DATE: 01/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/17/2023
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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