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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 419210027
Report Date: 07/18/2024
Date Signed: 07/18/2024 04:28:04 PM

Document Has Been Signed on 07/18/2024 04:28 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:DAVID'S HOMEFACILITY NUMBER:
419210027
ADMINISTRATOR/
DIRECTOR:
ROSE JOY GALERAFACILITY TYPE:
735
ADDRESS:1052 INVERNESS DRIVETELEPHONE:
(650) 593-2396
CITY:SAN CARLOSSTATE: CAZIP CODE:
94070
CAPACITY: 4CENSUS: 4DATE:
07/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:40 PM
MET WITH:Richard Morales, Direct Support Professional and Rose Joy Galera, Administrator TIME VISIT/
INSPECTION COMPLETED:
04:30 PM
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On July 18, 2024, Licensing Program Analysts(LPAs) John Calandra and Yi "Sam" Jian arrived at the facility at 2:40 PM, to conduct the unnanounced 1-year required Annual Inspection. LPAs Calandra and Jian were greeted by Richard Morales, Direct Support Professional(DSP) and explained the purpose of the visit. Rose Joy Galera, Administrator arrived later.

LPAs Calandra and Jian toured the physical plant. This is a 1-story building with three bathrooms, two bathrooms, a office, front yard, backyard, garage, kitchen, living room, dining room and family room. The facility was maintained at a comfortable temperature of 65 degrees Fahrenheit. The water temperature was measured within the required range of 105-120 degrees Fahrenheit. All bedrooms had the required furniture and sufficient lighting. No accessible bodies of water or hazards were observed in the hallways, back or front yards. The facility's fire extinguishers were last checked on April 30, 2024. Per an interview with Administrator, Rose Joy Galera, the facility's smoke alarms and carbon monoxide detectors are connected directly to the fire department. The first aid kit contained the required items such as sterile dressings, bandages, adhesive tape, scissors, tweezers, thermometers, antiseptic solution and guide. The facility has the required 7 days of non-perishables and 2 days of perishables on hand.

All sharp objects, poisons and cleaning supplies were observed to be locked and in-accessible to persons in care.

LPAs Calandra and Jian reviewed 4 client records. All were observed to be complete. The Annual inspection will be completed at a later date.

No deficiencies were cited during today's visit. An exit interview was conducted. This report was reviewed with Rose Joy Galera, Administrator and a copy of the report left at the facility.
SUPERVISORS NAME: Andrea Medlin
LICENSING EVALUATOR NAME: John Calandra
LICENSING EVALUATOR SIGNATURE: DATE: 07/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/18/2024
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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