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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601180
Report Date: 09/13/2024
Date Signed: 09/13/2024 03:56:24 PM

Document Has Been Signed on 09/13/2024 03:56 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:PECH5 MG OC LLCFACILITY NUMBER:
415601180
ADMINISTRATOR/
DIRECTOR:		VERMA, NEERUFACILITY TYPE:
740
ADDRESS:800 ROBLE AVENUETELEPHONE:
(408) 807-1984
CITY:MENLO PARKSTATE: CAZIP CODE:
94025
CAPACITY: 45CENSUS: 27DATE:
09/13/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:56 PM
MET WITH:Neeru VermaTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
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On 9/13/2024 LPAs Grace Donato & Kiran Jain made an unannounced pre-licensing visit to the facility. LPA met with Administrator Neeru Verma. LPA explained the purpose of the visit.

LPA toured the facility including random resident rooms, common areas & kitchen. The passageways were free of obstruction. Residents currently engaged in the activity room. 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 108 deg F. Carbon monoxide monitor is working properly. All fire extinguishers are in place and current. Facility has sprinkler system. Client bathrooms were observed to be in good repair equipped with grab bars and non-skid floors. LPA checked the food supply and there is adequate amount of food, 2 days for perishables and & 7 days non-perishable. Medication is updated and logged.

Three client records and three staff records were reviewed. Resident records are updated, complete and signed. Staff records are complete, with training logs.

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

No deficiencies are cited at this time. Report is reviewed and a copy is provided.
SUPERVISORS NAME: Andrea Medlin
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE: DATE: 09/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/13/2024
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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