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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601161
Report Date: 10/17/2023
Date Signed: 10/17/2023 12:49:30 PM


Document Has Been Signed on 10/17/2023 12:49 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:ARK, THEFACILITY NUMBER:
415601161
ADMINISTRATOR:APANDE, CAROLFACILITY TYPE:
740
ADDRESS:1320 VALOTA RDTELEPHONE:
(650) 995-7552
CITY:REDWOOD CITYSTATE: CAZIP CODE:
94061
CAPACITY:6CENSUS: 4DATE:
10/17/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Ivy VelasquezTIME COMPLETED:
12:55 PM
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On this day, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced prelicensing visit. LPA met with caregiver Ivy Velasquez and explained the purpose of today's visit. LPA contacted the licensee/administrator Carol Apande and informed her of LPAs presence at facility. She is unable to make it to the prelicensing on this day.

During today's visit, LPA toured the facility with independently and made observations through out the facility and the exterior surrounding areas of the facility. LPA observed that the fire place is not in use. The emergency exits around the facility are clear of obstructions and fences are not locked. Outdoor furniture in the front and backyard are in good condition for resident, staff, and visitor use. All resident rooms are furnished with the required furniture outlined in regulations. These items are in good repair. The facility ambient temperature is comfortable for residents and visitors. Bathrooms are observed as operational. Water is tested at all sinks at 115F and those faucets are operating properly. Fire extinguisher inspections tag is current showing 06/26/2023. Carbon monoxide and smoke detectors are hard wired through out the facility. Medications are locked and knives are locked away appropriately. Cleaning supplies are locked as well. Food supplies are in place. Resident and staff files are reviewed as complete and current. Staff training is current. Facility does not handle resident money. Administrator certificate is current.

Comp III orientation was given to the caregiver.

Pre-Licensing is complete. Licensure is recommended pending final approval from the Central Applications Bureau.

Report is reviewed with the caregiver Ivy and a copy of the report is provided. No citations issued.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:
DATE: 10/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/17/2023
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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