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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601156
Report Date: 09/03/2024
Date Signed: 09/03/2024 12:46:39 PM

Document Has Been Signed on 09/03/2024 12:46 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:CEDARHILL MANOR IIFACILITY NUMBER:
415601156
ADMINISTRATOR/
DIRECTOR:		CAYABYAB, CHRISTOPHERFACILITY TYPE:
740
ADDRESS:1117 EL CAMINO REAL, #1TELEPHONE:
(650) 242-5740
CITY:BURLINGAMESTATE: CAZIP CODE:
94010
CAPACITY: 4CENSUS: 3DATE:
09/03/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:25 PM
MET WITH:Caregiver, Norma SolisTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
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On September 3, 2024, Licensing Program Analyst (LPA) Murial Han conducted an unannounced plan of correction visit. LPA met with caregiver, Norma Solis and explained the purpose of today's visit.

During today's visit, LPA toured the facility and tested the hot water temperature in the kitchen and the bathroom and LPA observed the temperatures were measured at 108- 109 degrees Fahrenheit.

The follow deficiency from the annual inspection on 8/27/2024 is cleared:

87303(e)(2) (e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This report is reviewed and discussed with the caregiver and a copy is provided.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE: DATE: 09/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/03/2024
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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