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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601164
Report Date: 10/24/2023
Date Signed: 10/24/2023 02:12:16 PM

Document Has Been Signed on 10/24/2023 02:12 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:SEQUOIA HOMEFACILITY NUMBER:
415601164
ADMINISTRATOR:HERNANDEZ, JAYSONFACILITY TYPE:
740
ADDRESS:445 SEQUOIA AVENUETELEPHONE:
(408) 250-2543
CITY:REDWOOD CITYSTATE: CAZIP CODE:
94061
CAPACITY: 3CENSUS: 3DATE:
10/24/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Jayson HernandezTIME COMPLETED:
02:30 PM
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On this day, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced prelicensing visit. LPA met with administrator Jayson Hernandez and explained the purpose of today's visit.

During today's visit, LPA toured the facility with Jayson and made observations through out the facility and the exterior surrounding areas of the facility. LPA observed that there is no fireplace within the facility. 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 105F and those faucets are operating properly. Fire extinguisher inspections tag is current showing 06/20/2023. Carbon monoxide and smoke detectors are hard wired through out the facility. Facility equipped with full sprinkler system through out. 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 handle resident monies. These are audited and are current per logs reviewed money count. Surety bond is current expiring 11/18/2026. Administrator certificate expires 03/19/2024. Monthly fire drills are conducted and reviewed per log observed and major disaster drills are conducted quarterly per log.

Comp III orientation was provided to the administrator.

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

Report is reviewed with the administrator Jayson and a copy of the report is provided. No citations issued.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Jaime Vado
LICENSING EVALUATOR SIGNATURE: DATE: 10/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/24/2023
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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