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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 419210029
Report Date: 10/27/2023
Date Signed: 10/27/2023 11:39:42 AM

Document Has Been Signed on 10/27/2023 11:39 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
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:ZACK'S HOMEFACILITY NUMBER:
419210029
ADMINISTRATOR:MARIA CZARINA NAVARROFACILITY TYPE:
735
ADDRESS:210 CURLEW COURTTELEPHONE:
(650) 638-1300
CITY:FOSTER CITYSTATE: CAZIP CODE:
94404
CAPACITY: 4CENSUS: 4DATE:
10/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Administrator, Maria NavarroTIME COMPLETED:
11:48 AM
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On October 25, 2023, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced annual visit. LPA met with Administrator, Maria Navarro and explained the purpose of the visit.

LPA toured the facility inside and outside including all of resident rooms, common areas & kitchen. The indoor and outdoor passageways were free of obstruction. No accessible bodies of water of fire safety hazards observed. No residents were observed during the facility tour. According to the administrator, residents were at the day program. Extra linen was observed. One shared rooms and two private rooms with all required furnishings and bathrooms were observed to be in good repair and odor free.

A comfortable temperature of 69 degrees F is maintained and lighting is sufficient for comfort. Hot water was also tested between 107-115 degrees F throughout the facility. Sharps, toxins and medication were locked and inaccessible to residents. Carbon monoxide monitors are working properly. All fire extinguishers have been checked and current as of July 2023. LPA observed 2 days for perishables and 7 days non-perishables. Emergency drills are logged and done every three months.

LPA reviewed 4 resident records and 4 staff records. Resident records are updated, complete and signed. Staff records are complete, with training logs that have met the basic requirement. Medication review was done, and all medications are accounted for, and centrally stored medication records are updated.

No citations are issued during the visit. LPA reviewed report with Maria Navarro and a copy is provided.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE: DATE: 10/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/27/2023
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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