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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601151
Report Date: 02/16/2023
Date Signed: 02/16/2023 06:00:10 PM

Document Has Been Signed on 02/16/2023 06:00 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
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:HAPPY HOMEFACILITY NUMBER:
415601151
ADMINISTRATOR:ZAMORA, LOURDES R.FACILITY TYPE:
735
ADDRESS:3310 AEGEAN WAYTELEPHONE:
(650) 892-3152
CITY:SAN BRUNOSTATE: CAZIP CODE:
94066
CAPACITY: 2CENSUS: 0DATE:
02/16/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Lourdes ZamoraTIME COMPLETED:
06:00 PM
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Applicant Home for Special Needs LLC--represented by administrator Lourdes Zamora--has applied for ARF licensure for 2 ambulatory adults, aged 18 to 59 years old. Fire clearance has been approved.
LPA Jeung toured facility and grounds of this 4 bedroom 2-story home. Common areas--living/dining room, family room, kitchen, laundry room, sun room and 2 car garage--re on the ground level, including office room and full bathroom. There are 3 bedrooms and 2 full bathrooms on upper level. The yard consists of 3 paved levels, a greenhouse/chicken coop, storage shed, and a hillside covered with vegetation. A large expanse of the backyard is level. Medications and toxins are secured; toolboxes secured with combination locks are used for medications and toxins are stored in locked cabinets in garage, laundry room, and upstairs bathroom. Food preparation and service items are present, as well as perishable fruits, vegetables and protein. Combination smoke/carbon monoxide detectors are present and tested. Supplies of bed and bath linens and hygiene products are observed. Hot water temperature tested at 105 degrees F in client bathroom on 2nd floor. Facility sketch is consistent with facility floor plan observed, and utility shut-off locations are accurately stated on LIC610D,

LPA discussed with Ms. Zamora that emergency signal system may be required if clients and staff sleep on separate floors, as per Section 85088 Fixtures, Furniture, Equipment and Supplies.

The following items are observed and must be addressed prior to licensure:

1. Visitor log is not set up yet. This should include date, time, name, contact number, affirmation of absence of COVID symptoms.
2. COVID signs must be posted,prominently, including handwashing reminder signs at bathroom sinks.
3. Thirty-day supply of personal protective equipment (PPE)--gloves, hand sanitizers, gowns, masks, N95s--must be maintained.
4. Stairs to 2nd level may pose a safety hazard due to the wood grain pattern. Colored tape is advised to clearly delineate the steps. (Section 80087 Buildings and Grounds)
5. Seven-day supply of non-perishable canned fruits and vegetables must be maintained (Section 85076 Food Service)
Continued on next page
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Audrey Jeung
LICENSING EVALUATOR SIGNATURE: DATE: 02/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/16/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: HAPPY HOME
FACILITY NUMBER: 415601151
VISIT DATE: 02/16/2023
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6. Required information is not posted--personal rights as per LIC613, licensing complaint poster (If you see something, say something).

Ms. Zamora will contact LPA upon completion of above items, so a follow up visit can be scheduled.

Revised Emergency Disaster Plan (LIC610D) is provided to LPA today, and includes location of fire extinguishers on page 8.

Component III orientation is conducted with administrator Ms. Zamora.

Facility phone number is 650/372-5442
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Audrey Jeung
LICENSING EVALUATOR SIGNATURE:

DATE: 02/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2023
LIC809 (FAS) - (06/04)
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