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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601169
Report Date: 03/15/2024
Date Signed: 03/15/2024 03:54:25 PM

Document Has Been Signed on 03/15/2024 03:54 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:REGISTRY OF NURSES-ADULT ASSISTED LIVING FACILITYFACILITY NUMBER:
415601169
ADMINISTRATOR:YAMAT, FRANCIS H.FACILITY TYPE:
735
ADDRESS:32 LARKSPUR AVENUETELEPHONE:
(415) 533-0943
CITY:DALY CITYSTATE: CAZIP CODE:
94015
CAPACITY: 6CENSUS: 0DATE:
03/15/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Monalisa Yamat, Sylvestre Bongolan Jr., and Jeanel Gilo.TIME COMPLETED:
04:00 PM
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On March 15, 2024, at 1:45 PM, Licensing Program Analyst(LPA) John Calandra and Licensing Program Manager(LPM) Jackie Jin, arrived at the facility to conduct an announced pre-licensing visit as there are no clients currently. LPA Calandra and LPM Jin, met with Monalisa Yamat, Sylvestre Bongolan Jr., and Jeanel Gilo.

LPA Calandra and LPM Jin conducted a physical plant tour. The facility consists of 5 bedrooms, 3 bathrooms, a garage, staff room, laundry room, living room, kitchen, and office. Water temperature was measured at 126 degrees Fahrenheit. Jeanel turned down the water temperature in the presence of the LPA and LPM. The bedrooms were observed to have sufficient lighting and the required furniture. All bathrooms were observed to have the required grab bars and anti-skid mats. The facility had linens on hand for future clients that were observed to be in good condition. Food will be inspected during a future visit when clients are present in the facility. The front yard, backyard, and hallways were observed to be free from obstructions. The fire extinguisher was observed to be fully charged and last checked on 9/25/2023.

A component III was performed with the applicant.

LPA Calandra and LPM Jin asked the applicant to address the following:

-Ensure water temperature is lowered to between 105 and 120 degrees Fahrenheit
-Fix tile on side of house
-Clear a pathway in Garage if needed for emergency evacuation
-Clear stored items in backyard
-Replace latch on front gate
-Ensure all door alarms are operational with their own batteries
-Ensure each bedroom has drawer space to accommodate the client's clothing and personal belongings.

LPA will return to conduct a follow-up visit to ensure the above items have been addressed.

The report was reviewed with Monalisa Yamat, Sylvestre Bongolan Jr., and Jeanel Gilo. A copy of the report was left at the facility.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: John Calandra
LICENSING EVALUATOR SIGNATURE: DATE: 03/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/15/2024
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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