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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601173
Report Date: 01/16/2025
Date Signed: 01/16/2025 05:55:27 PM

Document Has Been Signed on 01/16/2025 05:55 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:JERRY'S CARE HOMEFACILITY NUMBER:
415601173
ADMINISTRATOR/
DIRECTOR:		BRANCH, KAILAFACILITY TYPE:
735
ADDRESS:2501 OAKMONT DRIVETELEPHONE:
(650) 636-4048
CITY:SAN BRUNOSTATE: CAZIP CODE:
94066
CAPACITY: 6CENSUS: 0DATE:
01/16/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:40 AM
MET WITH:Administrator, Kaila BranchTIME VISIT/
INSPECTION COMPLETED:
11:55 AM
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On January 16, 2025, Licensing Program Analyst (LPA), Murial Han and Licensing Program Manager (LPM) April Cowan met with the Administrator, Kaila Branch and RN Consultant, Tina Desuasido to conduct a pre-licensing inspection.

The administrator provided a tour of the facility and LPA and LPM observed the indoor and the outdoor passageways are free of obstruction. This is a single level facility. There is no residents during the time of the inspection. LPA observed good lighting thought-out the facility and comfortable temperature is maintained. Bed sheets, linens, and towels were observed to be sufficient and able to meet the needs of the residents at this time.

LPA observed sufficient hygiene and cleaning supplies. Trash cans in the kitchen have tight fitting, and foot operated lids. LPA observed sufficient amount of utensils, cooking wares and cleaning supplies. LPA observed some perishable and some non-perishable food items, however, not meeting the requirement as 2- days perishables and 7- days of non-perishables because there is no resident at this time.

LPA observed postings including CCL complaint poster, resident's rights, house rules and according to the administrator, the Ombudsman poster has been ordered.

The facility is clean and tidy. There are 4 bedrooms( 2 shared resident rooms and 2 privates)

The water temperature in the kitchen, the bath/shower rooms were measured at 107-117 degrees Fahrenheit. LPA observed laundry supplies and equipment to be adequate.

Pre-Licensing is incomplete during this inspection due to the following area of concern:
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE: DATE: 01/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/16/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: JERRY'S CARE HOME
FACILITY NUMBER: 415601173
VISIT DATE: 01/16/2025
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The facility does not have an auditory devices on the exterior doors to alert staff when the door is opened as the facility is pending licensure for 2 ambulatory clients.

LPA recommended to label the resident's bedroom to identified the approved non-ambulatory and ambulatory rooms.

Comp III orientation is completed.

The administrator acknowledged the above observation. A follow-up pre-licensing inspection will be scheduled.

Exit interview conducted with administrator and RN consultant.

A copy of this report is provided.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:

DATE: 01/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2025
LIC809 (FAS) - (06/04)
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