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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601156
Report Date: 07/12/2023
Date Signed: 07/12/2023 04:22:15 PM


Document Has Been Signed on 07/12/2023 04:22 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:CEDARHILL MANOR IIFACILITY NUMBER:
415601156
ADMINISTRATOR:FORONDA-CAYABYAB, MARIE JAFACILITY TYPE:
740
ADDRESS:1117 EL CAMINO REAL, #1TELEPHONE:
(650) 242-5740
CITY:BURLINGAMESTATE: CAZIP CODE:
94010
CAPACITY:4CENSUS: 0DATE:
07/12/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Marie and Chris CayabyabTIME COMPLETED:
04:30 PM
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Applicant CHM Group LLC--represented by administrators Christopher and Marie Jan Cayabyab--has applied for RCFE licensure for 4 ambulatory elderly, aged 60 and older. Fire clearance has been approved.
LPA Jeung toured facility and grounds of this 2 bedroom 2-story duplex. Common areas--living/dining room, kitchen, and 2 client bedrooms and full bathroom--are on the ground level. On the upper level, there is a large room and closet, which will be used for storage or by staff. The outside area consists of level paved driveways; there is no enclosure. Medications and toxins will be secured in metal file cabinet in living room and in under sink cabinet in kitchen. Washer and dryer are in the basement level, accessed from outside at rear of building. Emergency signal system consists of battery operated pendants for each resident, bathroom and kitchen, which transfer audible alarm to main unit on upper level. Food preparation and service items are present, as well as non-perishable fruits 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. Facility sketch is consistent with facility floor plan observed, and utility shut-off locations are accurately stated on LIC610D. Revised page 3 of Emergency Disaster Plan and facility sketch are provided to LPA.

The following items are observed and must be addressed prior to licensure:
1. Hot water temperature tested at 130 degrees in bathroom sink and must be maintained between 105 and 120 degrees F. (Section 87303 Maintenance and Operation)
2. Seven-day supply of non-perishable canned vegetables must be maintained (Section 87555 General Food Service)
3. COVID signs, including hand washing reminder in bathroom, should be posted prominently.
4. Thirty-day supply of personal protective equipment (PPE)--gloves, hand sanitizers, gowns, masks, N95s--should be maintained.

Applicants will contact LPA upon completion of above items, so a follow up visit can be scheduled.
Component III orientation is conducted with administrators. Facility phone number is 650/242-5740.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:
DATE: 07/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/12/2023
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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