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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601161
Report Date: 10/03/2024
Date Signed: 10/03/2024 03:52:02 PM

Document Has Been Signed on 10/03/2024 03:52 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:ARK, THEFACILITY NUMBER:
415601161
ADMINISTRATOR/
DIRECTOR:
APANDE, CAROLFACILITY TYPE:
740
ADDRESS:1320 VALOTA RDTELEPHONE:
(650) 995-7552
CITY:REDWOOD CITYSTATE: CAZIP CODE:
94061
CAPACITY: 6CENSUS: 6DATE:
10/03/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:33 PM
MET WITH:Carol Apande, Administrator and Yrvanie Velasquez, Caretaker TIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
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On October 3, 2024, Licensing Program Analyst(LPA) John Calandra arrived at the facility at 12:33 PM to conduct the Annual 1-year required inspection. LPA Calandra was greeted by Yrvanie Velsaquez, Caretaker and explained the purpose of the visit. Carol Apande, Administrator arrived later during the visit.

LPA Calandra toured the physical plant. This is a 1-story building with 6 bedrooms and 4 and a half bathrooms, a living room, kitchen and backyard. No accessible bodies of water or hazards were observed. All bedrooms had the required furniture and sufficient lighting. Hot water temperature was measured between the required 105-120 degrees Fahrenheit. All bathrooms had the required grab bars and anti-skid floor mats. The facility had the required 2 days of perishables but not the required 7 days of non perishables. The facility's fire alarms and carbon monoxide detectors were observed to be in working order.

All sharp objects, poisons, soaps, and detergents were observed to be locked and in-accessible to persons in care.

LPA Calandra reviewed 4 staff files and 5 resident files. All were observed to be complete.

LPA Calandra requested and received the following documents at the facility:

-Current Liability Insurance
-Administrator's Certificate

A review of Centrally Stored Medications indicated that medications for residents were properly labeled with instructions on dosage and times of day and matched the Centrally Stored Medication Records(CSMR) kept at the facility.

The deficiencies are cited under the California Code of Regulations, Title 22. Failure to correct the deficiencies by the due date may result in civil penalties.

An exit interview was conducted. This report was reviewed with Carol Apande, Administrator and a copy of the report along with Appeal rights left at the facility.




SUPERVISORS NAME: Andrea Medlin
LICENSING EVALUATOR NAME: John Calandra
LICENSING EVALUATOR SIGNATURE: DATE: 10/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/03/2024
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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Document Has Been Signed on 10/03/2024 03:52 PM - It Cannot Be Edited


Created By: John Calandra On 10/03/2024 at 03:17 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: ARK, THE

FACILITY NUMBER: 415601161

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 10/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87555(b)(26)
General Food Service Requirements
(b) The following food service requirements shall apply: (26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 1 out 1 instances in which there was not enough supply of canned goods/7-days worth of non-perishable foods in the facility, which poses an immediate health, safety, or personal rights risk to persons in care.
POC Due Date: 10/04/2024
Plan of Correction
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Administrator/Licensee to submit proof of correction and a written plan outlining how this violation will be avoided in the future to licensing office by due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Andrea Medlin
LICENSING EVALUATOR NAME:John Calandra
LICENSING EVALUATOR SIGNATURE:
DATE: 10/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/03/2024


LIC809 (FAS) - (06/04)
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