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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 419210013
Report Date: 10/14/2024
Date Signed: 10/15/2024 08:16:39 AM

Document Has Been Signed on 10/15/2024 08:16 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:PARTNERS FOR INDEPENDENCE- INCLUSION CTR.FACILITY NUMBER:
419210013
ADMINISTRATOR/
DIRECTOR:		EMMANUEL CANONFACILITY TYPE:
775
ADDRESS:1608 GILBRETH ROADTELEPHONE:
(650) 259-8065
CITY:BURLINGAMESTATE: CAZIP CODE:
94010
CAPACITY: 60CENSUS: 34DATE:
10/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Program Director - Renz CorralesTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
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On 10/14//2024, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced required - 1 year inspection visit. LPA met with the program director Renz Corrales and explained the purpose of today's inspection. Currently there are 32 clients attending the program present today and 23 staff in place including the program director.

This is a single level facility and licensed to serve age range of 18 and over. 10 clients all may be non-ambulatory. The physical plant was toured inside and outside of the facility to ensure the safety of the clients. There are no cameras present in the facility. LPA observed the facility kitchen which is clean and observed appliances that are in good repair. Clients bring their own lunches into the program and snacks. LPA observed client lockers where they store belongings and lunches. Any sharps such as knives are locked in the staff break room. This is observed during inspection. First aid kits are observed as complete with required items stored in the front office and in the "cabinet room". This program handles some client medications. LPA observed that there are multiple fire extinguishers in place all serviced in 2024, smoke detectors, carbon monoxide detectors are observed in place through out the facility, and central HVAC. Facility is equipped with fire sprinklers. PPE is observed to be in place stored in the garage area of the facility. Emergency exit routes are observed inside and outside to be free and clear of obstructions. Last emergency/disaster drill was conducted on 09/16/2023. Cleaning supplies and toxins are observed to be locked in a storage room and garage. Water temperature is measured at 115F in a common client restroom. Facility is equipped with 4 client bathrooms all of which are in good condition and operating.

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SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Jaime Vado
LICENSING EVALUATOR SIGNATURE: DATE: 10/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/14/2024
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 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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
VISIT DATE: 10/14/2024
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Page 2 - Annual inspection

There are several activity rooms in this day program and all are observed to be in order. There are 4 client bathrooms are unisex and observed today equipped appropriately and good working order. During today's inspection LPA reviewed 5 client files and 5 staff files all of which are current. Facility does not handle client monies. Facility maintains a 3:1 staffing ratio per discussions with the director.

The following updated forms are requested to be submitted to CCLD by 10/21/2024:

• Copy of facility's liability insurance
• LIC308 Designation of responsible staff person
• LIC610D Emergency Disaster Plan
• LIC500 Staff Schedule
• Copy of control of property or copy of lease

No citations issued on this day. Report is reviewed with Renz Corrales and a copy is provided.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Jaime Vado
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2024
LIC809 (FAS) - (06/04)
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