<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 419210011
Report Date: 09/13/2023
Date Signed: 09/13/2023 03:23:34 PM

Document Has Been Signed on 09/13/2023 03:23 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
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:SOCIAL DYNAMICS, A LIFE STEPS FOUNDATION.INC.PROGFACILITY NUMBER:
419210011
ADMINISTRATOR:ALAIN GREGORIOFACILITY TYPE:
775
ADDRESS:828C MAHLER ROADTELEPHONE:
(650) 259-1808
CITY:BURLINGAMESTATE: CAZIP CODE:
94010
CAPACITY: 69CENSUS: 33DATE:
09/13/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Administrator, Alain GregorioTIME COMPLETED:
12:05 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On September 13, 2023, Licensing Program Analysts (LPAs) Murial Han arrived unannounced to conduct an annual continuation for an annual required inspection conducted on August 30, 2023. LPA met with administrator, Alain Gregorio. LPA explained the purpose of the visit.

During today's visit, LPA reviewed 5 client records contained resident's identification and emergency information, admission agreement, medical assessment, LIC 602 (Physician Order), Appraisal Needs and Service Plan, GGRC/IPP, etc.

LPA also interviewed 5 facility staff.

No deficiencies cited today.

This report is reviewed and discussed with administrator

A copy is provided.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE: DATE: 09/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/13/2023
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 1