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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601156
Report Date: 07/24/2023
Date Signed: 07/24/2023 10:01:15 AM

Document Has Been Signed on 07/24/2023 10:01 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: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:
07/24/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Chris CayabyabTIME COMPLETED:
10:15 AM
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LPAs Calandra and Jeung reviewed items referenced on 7/12/23 during initial pre-licensing visit.
The following items have been addressed:

1. Hot water temperature tested at 110 degrees in bathroom sink and is maintained between 105 and 120 degrees F. (Section 87303 Maintenance and Operation)
2. Seven-day supply of non-perishable canned vegetables is maintained (Section 87555 General Food Service)
3. COVID signs, including hand washing reminder in bathroom, are posted prominently.
4. Thirty-day supply of personal protective equipment (PPE)--gloves, hand sanitizers, gowns, masks, N95s--is maintained.

Component III orientation was conducted with administrators on 7/12/23.

Facility meets physical plant requirements of Title 22 regulations for RCFEs. Immediate licensure is recommended pending approval by Central Applications Unit analyst.

Facility phone number is 650/242-5740.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Audrey Jeung
LICENSING EVALUATOR SIGNATURE: DATE: 07/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/24/2023
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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