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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 419210025
Report Date: 05/28/2024
Date Signed: 05/28/2024 12:29:41 PM

Document Has Been Signed on 05/28/2024 12:29 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:FOCUS DAY PROGRAMFACILITY NUMBER:
419210025
ADMINISTRATOR/
DIRECTOR:		YOLANDA T. RUIZFACILITY TYPE:
775
ADDRESS:715 SAN MATEO AVE.TELEPHONE:
(650) 589-2948
CITY:SAN BRUNOSTATE: CAZIP CODE:
94066
CAPACITY: 75CENSUS: 41DATE:
05/28/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Program Director, Willie RazTIME VISIT/
INSPECTION COMPLETED:
12:45 PM
NARRATIVE
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On May 28, 2024 Licensing Program Analyst (LPA) Murial Han conducted an unannounced annual inspection. Upon entry, LPA met with Program Director, Willie Raz and the administrator, Yolanda Ruiz arrived shortly thereafter and LPA explained the purpose of the visit.

LPA toured facility and grounds with the program director. No accessible bodies of water or fire safety hazards observed. The indoor and outdoor passageways were free of obstruction. LPA toured the facility activity rooms, changing rooms, storage rooms and kitchen area.

LPA observed 2 large activity rooms- one for the ARF clients and the other is for the RCFE clients and the activities are designed pertaining to their age group.

Three fire extinguishers, two pull alarm, sprinklers, smoke detectors, carbon monoxide detectors are all present on premises. Hot water temperature was measured at 105- 107 degrees F. A comfortable temperature is maintained and lighting is sufficient for comfort.

LPA observed chemical, toxins and sharps are locked and inaccessible to residents in care.

Clients belongings/lunches were observed to be stored on carts throughout the facility.

Fire extinguishers were last inspected on 5/16/2024.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE: DATE: 05/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/28/2024
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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Document Has Been Signed on 05/28/2024 12:29 PM - It Cannot Be Edited


Created By: Murial Han On 05/28/2024 at 11:48 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: FOCUS DAY PROGRAM
FACILITY NUMBER: 419210025

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/28/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82068(a)
Admission Agreements
(a) The licensee shall complete and maintain an individual written admission agreement with each client and the client's authorized representative, if any.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, record review and interview, the licensee did not comply with the section cited above as LPA observed 2 clients did not have an admission agreement and 4 client's admission agreements were incomplete as they were missing RP, and Licensee/Administrator signatures which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/05/2024
Plan of Correction
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The administrator will develop a plan to ensure compliance and will provide a copy of the completed admission agreement to CCL by 6/5/2024.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Cara Smith
LICENSING EVALUATOR NAME:Murial Han
LICENSING EVALUATOR SIGNATURE:
DATE: 05/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/28/2024


LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: FOCUS DAY PROGRAM
FACILITY NUMBER: 419210025
VISIT DATE: 05/28/2024
NARRATIVE
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 A review of (6) client files were conducted and noted on the LIC 858.
A review of (5) staff files was conducted and noted on the LIC 859.

Deficiency of the California Code of Regulations, Title, 22 cited on the LIC 809D. Failure to correct the deficiencies may result in civil penalties.

This report is reviewed and discussed with the administrator and program director.

A copy of this report and appeal rights were provided.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2024
LIC809 (FAS) - (06/04)
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