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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601164
Report Date: 11/06/2024
Date Signed: 11/06/2024 04:36:20 PM

Document Has Been Signed on 11/06/2024 04:36 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:SEQUOIA HOMEFACILITY NUMBER:
415601164
ADMINISTRATOR/
DIRECTOR:
HERNANDEZ, JAYSONFACILITY TYPE:
740
ADDRESS:445 SEQUOIA AVENUETELEPHONE:
(650) 216-9709
CITY:REDWOOD CITYSTATE: CAZIP CODE:
94061
CAPACITY: 3CENSUS: 3DATE:
11/06/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Jayson Hernandez, AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:36 PM
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On November 6, 2024, Licensing Program Analyst(LPA) John Calandra arrived at the facility at 2:00 PM to conduct the unannounced Annual 1-year required inspection. LPA Calandra was greeted by Jayson Hernandez, Administrator and explained the purpose of the visit.

LPA Calandra toured the physical plant. This is a 1-story building with 3 bedrooms, 2 bathrooms, kitchen, living room, dining room, garage, and a backyard. No accessible bodies of water or hazards were observed. All bedrooms had the required furniture and sufficient lighting. The facility's hot water temperature was measured within the required 105-120 degrees Fahrenheit. The facility's first aid kit had the required items. The facility's smoke alarms and carbon monoxide detectors were observed to be in working order.

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

LPA Calandra reviewed 3 resident files and 5 staff files. All were observed to be complete.

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.

All Personal and Incidental (P & I) monies kept at the facility matched the records stored at the facility.

During the visit, the following documents were collected:
- Liability Insurance
-CNA Surety Bond
-Current LIC 500

No deficiencies were cited during today's visit.

An exit interview was conducted. This report was reviewed with Jayson Hernandez, Administrator and a copy of the report left at the facility.
SUPERVISORS NAME: Andrea Medlin
LICENSING EVALUATOR NAME: John Calandra
LICENSING EVALUATOR SIGNATURE: DATE: 11/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/06/2024
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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