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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 419210029
Report Date: 11/14/2024
Date Signed: 11/14/2024 11:29:55 AM

Document Has Been Signed on 11/14/2024 11:29 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:ZACK'S HOMEFACILITY NUMBER:
419210029
ADMINISTRATOR/
DIRECTOR:
MARIA CZARINA NAVARROFACILITY TYPE:
735
ADDRESS:210 CURLEW COURTTELEPHONE:
(650) 638-1300
CITY:FOSTER CITYSTATE: CAZIP CODE:
94404
CAPACITY: 4CENSUS: 4DATE:
11/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Administrator Maria NavarroTIME VISIT/
INSPECTION COMPLETED:
11:45 AM
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On November 14, 2024 Licensing Program Analyst (LPA) Murial Han 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. Extra linen was observed. One shared room and two private rooms with all required furnishings and bathrooms were observed to be in good repair and odor free.

A comfortable temperature is maintained and lighting is sufficient for comfort. Hot water temperature in the bathrooms and kitchen were measured at 111-115 degrees F.

Sharps, toxins and medication were locked and inaccessible to residents. Smoke detectors and carbon monoxide were observed to be adequate. Fire extinguishers were last inspected on 7/16/2024. 2 days for perishables and 7 days non-perishables were observed. Emergency drills were reviewed. Emergency Disaster supplies are stored in the garage.

A review of (4) resident files was conducted and noted on the LIC 858.
A review of (3) staff files was conducted and noted on the LIC 859.

P & I were reviewed for 4 residents and observed to be adequate.

During the visit, there was no residents present at the facility and according to the administrator, they were all attending the community based activities.

Administrator certificate has expired, however, the renewal process has been completed. Administrator will provide a copy when obtained.

No citations are issued during the visit. LPA reviewed report with Maria Navarro and a copy is provided.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE: DATE: 11/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/14/2024
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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