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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601165
Report Date: 01/23/2024
Date Signed: 01/24/2024 08:39:21 AM


Document Has Been Signed on 01/24/2024 08:39 AM - 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:DOUBLE HAPPINESS RESIDENTIAL CARE HOMEFACILITY NUMBER:
415601165
ADMINISTRATOR:MEHTA, IRENEFACILITY TYPE:
740
ADDRESS:859 CAMARITAS CIRTELEPHONE:
(415) 741-4768
CITY:SOUTH SAN FRANCISCOSTATE: CAZIP CODE:
94080
CAPACITY:6CENSUS: 3DATE:
01/23/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:25 PM
MET WITH:Irene MehtaTIME COMPLETED:
04:30 PM
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On 1/23/24 LPA Grace Donato made an unannounced pre-licensing visit to the facility. LPA met with Administrator Irene Mehta. LPA explained the purpose of the visit.

LPA toured the facility inside and outside including all of resident rooms, common areas & kitchen. The indoor and outdoor passageways were free of obstruction. The residents have adequate amount of linens and all personal belongings are intact. While touring the facility it was observed that the room temperature was at 69 deg F. Hot water was also tested in the bathrooms and the temperature was 110 deg F. Carbon monoxide monitor is working properly. All fire extinguishers have been checked and current. Client bathrooms were observed to be in good repair equipped with grab bars and non-skid mats. LPA checked the food supply and there is adequate amount of food, 2 days for perishables and & 7 days non-perishable.

Medication review was done, and all medications are accounted for, and centrally stored medication records are updated. Three client records and three staff records were reviewed. Resident records are updated, complete and signed.

Facility is clean and in good repair based on observations made today. Facility is in compliance with Title 22 regulations. Component III is also conducted on this day. No citations are issued.

No deficiencies are cited at this time. Report is reviewed and a copy is provided.
SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8865
LICENSING EVALUATOR NAME: Grace DonatoTELEPHONE: (714) 293-8294
LICENSING EVALUATOR SIGNATURE:
DATE: 01/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/23/2024
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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