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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601151
Report Date: 03/22/2023
Date Signed: 03/22/2023 05:55:11 PM

Document Has Been Signed on 03/22/2023 05:55 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:
03/22/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
05:30 PM
MET WITH:Lisa ZamoraTIME COMPLETED:
06:00 PM
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LPA Jeung inspected facility to follow up on previous pre-licensing visit of 2/16/23.

The following items have been addressed:

1. Visitor log is set up and includes date, time, name, contact number, affirmation of absence of COVID symptoms.
2. COVID signs are posted,prominently, including handwashing reminder signs at bathroom sinks.
3. Thirty-day supply of personal protective equipment (PPE)--gloves, hand sanitizers, gowns, masks, N95s--is observed.
4. Reflective tape has been applied to wood grain stairs to 2nd level as a safety measure to clearly delineate the steps. (Section 80087 Buildings and Grounds)
5. Seven-day supply of non-perishable canned fruits and vegetables is observed. (Section 85076 Food Service)
6. Required information--personal rights as per LIC613 and licensing complaint poster (If you see something, say something)--is posted.

Component III orientation was conducted on 2/16/23.

Facility meets Title 22 physical plant requirements for licensure as Adult Residential Facility for 2 ambulatory adults. Immediate licensure is recommended, pending final approval from Centralized Application Unit.

Facility phone number is 650/372-5442.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Audrey Jeung
LICENSING EVALUATOR SIGNATURE: DATE: 03/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/22/2023
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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