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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601193
Report Date: 12/19/2024
Date Signed: 12/19/2024 12:14:44 PM

Document Has Been Signed on 12/19/2024 12:14 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:DOLPHIN PARK REST HOME #3FACILITY NUMBER:
415601193
ADMINISTRATOR/
DIRECTOR:		CONANAN,EVELYNFACILITY TYPE:
740
ADDRESS:380 GUNTER LANETELEPHONE:
(650) 593-4965
CITY:REDWOOD CITYSTATE: CAZIP CODE:
94065
CAPACITY: 6CENSUS: 3DATE:
12/19/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Administrator, Evelyn ConananTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
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On December 19, 2024, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced pre-licensing visit. LPA met with Licensee/Administrator, Evelyn Conanan and explained the purpose of the visit.

LPA toured facility and grounds. No accessible bodies of water or fire safety hazards observed. Indoor and outdoor passageways were observed free from obstruction. This is a single level facility with 6 private resident rooms with half baths in each bedroom, 1 full bathroom, and 1 staff room. Three residents were present during the visit. All resident rooms were observed to be clean and in good repair, with all required furnishing. Bathrooms were observed to be odor-free, equipped with grab-bars, liquid soap and paper towels. Non-skid mat was observed present in the full bathroom. Water temperature throughout the facility measured between 117-120 degrees F.

Living room and dining room is observed clean and free from tripping hazards. Lighting is sufficient for comfort and a comfortable temperature is maintained throughout the facility. LPA observed two day perishable and seven day non-perishables. Sharps, chemicals and medications were observed to be locked an inaccessible to residents. Carbon monoxide monitors are working properly. All fire extinguishers have been checked and current as of April 2024. First aid kit was observed to be present and complete.

LPA observed postings such as the Licensing Complaint Poster, Resident Rights, etc.

Pre-Licensing is complete. Immediate Licensure is recommended pending final approval from the Central Applications Bureau. Component III orientation was reviewed with the Licensee/Administrator.

This report is reviewed and discussed with the Licensee/Administrator, Evelyn Conanan and a copy is provided.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE: DATE: 12/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/19/2024
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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