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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 419200006
Report Date: 09/25/2024
Date Signed: 09/25/2024 11:36:18 AM

Document Has Been Signed on 09/25/2024 11:36 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:GIFT OF LOVEFACILITY NUMBER:
419200006
ADMINISTRATOR/
DIRECTOR:
SISTER M.FAUSTINE MCFACILITY TYPE:
736
ADDRESS:160 MILAGRA DRIVETELEPHONE:
(650) 557-0354
CITY:PACIFICASTATE: CAZIP CODE:
94044
CAPACITY: 13CENSUS: 6DATE:
09/25/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:48 AM
MET WITH:Sister FaustineTIME VISIT/
INSPECTION COMPLETED:
11:50 AM
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On 9/25/2024, Licensing Program Analyst (LPA) Tobola conducted an unannounced Annual Required – 1 yr. inspection for this facility and was greeted by Sister Faustine. The facility currently provides care for 6 residents.

LPA continued with a tour of the facility with Sister Faustine, facility found to be clean and at a comfortable temperature with all exits free from obstruction. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was found to be charged. Smoke and carbon monoxide detectors observed in the hallways were interconnected and in functioning order with a recently completed fire safety inspection in February 2024.

There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations, with food stored in the kitchen refrigerator found to have appropriate coverings, enough for residents in care. Cleaning supplies and other toxins are safely stored in locked cabinets in laundry room, all of which were secured upon inspection. There was a supply of hygiene products and paper products available for residents. All resident’s bedrooms have lighting & appropriate furnishings and bedding items with plenty of additional linen supplies. Residents that were awake during the inspection were observed interacting with staff/volunteers in their bedrooms, in addition to the facility encouraging regular family visits. In addition, there is a large outdoor patio with appropriate shade and activity/exercise equipment for resident use. Upon a sample review of staff and resident files, LPA found all items to be in order and updated. Lastly, LPA conducted a spot check of medications and found all medications and records to be accurately documented.

LPA requested the following documents be sent to CCL by COB 10/9/2024:
LIC 308 Designated Facility Responsibility
LIC 610 Emergency Disaster Plan
Liability Insurance

No deficiencies cited.
SUPERVISORS NAME: Andrea Medlin
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE: DATE: 09/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/25/2024
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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