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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 419210013
Report Date: 10/09/2023
Date Signed: 10/09/2023 03:02:37 PM

Document Has Been Signed on 10/09/2023 03:02 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:PARTNERS FOR INDEPENDENCE- INCLUSION CTR.FACILITY NUMBER:
419210013
ADMINISTRATOR:EMMANUEL CANONFACILITY TYPE:
775
ADDRESS:1608 GILBRETH ROADTELEPHONE:
(650) 259-8065
CITY:BURLINGAMESTATE: CAZIP CODE:
94010
CAPACITY: 60CENSUS: 32DATE:
10/09/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Renzrudolp CorralesTIME COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to conduct a Required – 1 Year inspection on 10/9/23 at 12:00pm. LPA met with Renz Corrales, Program Director and stated the purpose of today’s visit. LPA was allowed entry into the facility that is licensed to serve a total capacity of 60 clients of which 10 maybe non-ambulatory. Annual Fees are current. Facility staff roster provided during this visit. Administrator certificate expired 4/16/2023. LPA observed the receipt and classes of renewal that was submitted to Community Care Licensing (CCL) during this visit. LPA observed an Designation of Facility Responsibility (LIC308) for Renz Corrales.

Upon arrival LPA observed clients participating in activities. The physical plant was toured inside and outside to ensure the safety of the residents. LPA observed the facility does not prepare food for the clients. LPA observed the most recent emergency drill was conducted on 3/7/23. LPA observed fire extinguisher(s), smoke and carbon monoxide detectors, central heating and air in the facility. The temperature inside the facility was measured at 72*F which is within the required range of 68 degrees F (20 degrees C) and 85 degrees F (30 degrees C), or in areas of extreme heat the maximum shall be 30 degrees F (16.6 degrees C) less than the outside temperature. The hot water was measured at 117.9 *F which is not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C) as per Title 22 regulations. The facility has 2 water tanks of which 1 was replaced in August 2023. LPA observed the medications area to be locked and inaccessible to clients. The first aid kit was found in compliance containing at least the following: a current edition of a first aid manual approved by the American Red Cross, the American Medical Association or a state or federal health agency, sterile first aid dressings, bandages or roller bandages, adhesive tape, scissors, tweezers, thermometers, and antiseptic solution. LPA reviewed 2 staff and 2 resident files and conducted interviews during this visit.

Upon a file review the following items were discussed to be submitted with any changes annually:
Any addendums to the Infection Control Plan, Designation of Facility Responsibility (LIC308), Personnel Report (LIC500) to include the Administrator/Program Director presence in the facility, Administrator Certificate-Updated, Emergency Disaster Plan (LIC610E), and Health Screening with TB for all staff.

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 6, no deficiencies are being cited. An exit interview was conducted, a copy of the report was given.
SUPERVISORS NAME: Victoria Brown
LICENSING EVALUATOR NAME: Victoria Brown
LICENSING EVALUATOR SIGNATURE: DATE: 10/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/09/2023
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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