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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 419210027
Report Date: 08/08/2024
Date Signed: 08/08/2024 04:06:04 PM

Document Has Been Signed on 08/08/2024 04:06 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:
08/08/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:30 PM
MET WITH: Rose Joy Galera, Administrator TIME VISIT/
INSPECTION COMPLETED:
04:15 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 August 8, 2024, Licensing Program Analysts(LPAs) John Calandra and Kiran Jain arrived at the facility at 2:30 PM to complete the Annual 1-year required inspection started on July 18, 2024. LPAs Calandra and Jain were greeted by Rose Joy Galera, Administrator and explained the purpose of the visit.

LPAs Calandra and Jain interviewed 4 clients and 2 staff.

LPAs Calandra and Jain reviewed 5 staff records. All were observed to be complete.

All P&I monies were accounted for and matched the records kept at the facility.

A Type B Violation was provided for not providing a shaded area in the outdoor activity area.

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

An exit interview was conducted. This report was reviewed with Rose Joy Galera, Administrator and a copy of the report along with Appeal Rights left at the facility.
SUPERVISORS NAME: Andrea Medlin
LICENSING EVALUATOR NAME: John Calandra
LICENSING EVALUATOR SIGNATURE: DATE: 08/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/08/2024
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
Document Has Been Signed on 08/08/2024 04:06 PM - It Cannot Be Edited


Created By: John Calandra On 08/08/2024 at 03:38 PM
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: DAVID'S HOME
FACILITY NUMBER: 419210027

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85087.2(b)
Outdoor Activity Space
(b) The outdoor activity area shall provide a shaded area, and shall be comfortable, and furnished for outdoor use.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
CCR 85087.2(b): Outdoor Activity Space: Based on observation, the licensee did not comply with the section cited above in 1 out of 1 backyards, which did not have any shade for clients to participate in outdoor activities, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/22/2024
Plan of Correction
1
2
3
4
Licensee/Administrator to submit proof of correction and a written plan outlining how this violation will be avoided in the future to licensing office by due date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:Andrea Medlin
LICENSING EVALUATOR NAME:John Calandra
LICENSING EVALUATOR SIGNATURE:
DATE: 08/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/08/2024


LIC809 (FAS) - (06/04)
Page: 2 of 2