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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 419210038
Report Date: 10/14/2023
Date Signed: 10/14/2023 06:21:12 PM

Document Has Been Signed on 10/14/2023 06:21 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:ESCANYO HOMEFACILITY NUMBER:
419210038
ADMINISTRATOR:TERESITA GOFACILITY TYPE:
735
ADDRESS:151 ESCANYO DRIVETELEPHONE:
(650) 952-7900
CITY:SOUTH SAN FRANCISCOSTATE: CAZIP CODE:
94080
CAPACITY: 6CENSUS: 6DATE:
10/14/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
04:45 PM
MET WITH:Elizabeth GacesTIME COMPLETED:
06:30 PM
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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to conduct a Required - 1 Year visit on 10/14/23 at 4:45pm. LPA met with Jefrey Torrea, Caregiver who contacted Teresita Go, Administrator regarding todays visit. Elizabeth Gaces, Caregiver arrived to assist with todays visit. The caregiver(s) are fingerprint cleared and associated to the facility.

The administrator certificate for Teresita Go expired on 6/3/23. LPA observed a Community Care Licensing print out which indicates the Department has received the pertinent documents and payment for renewal as of 2/24/23.
The facility is licensed for a capacity of 6 ambulatory residents.
LPA toured and inspected the physical plant inside and outside to ensure there are no safety hazards to residents. The temperature inside the facility was observed to be at 74 *F which is within the required range of 68-85*F. The hot water temperature was measured at 107.3*F which is within the required range of 105-120*F.
LPA observed fire extinguisher(s), pull alarm system, smoke and carbon monoxide detectors in the facility.
LPA observed the centrally stored medications area to be locked and inaccessible to residents.
The first aid kit contained the required items such as sterile dressings, bandages, adhesive tape, scissors, tweezers, thermometers, antiseptic solution and guide.
LPA observed P&I monies for resident #1 (R1) was counted, documented, and not commingled during this visit.
The most recent emergency drill was conducted on 10/2/23.
LPA observed 2-day perishables and 7-day non-perishables.

Upon a file review the following items were discussed to be submitted with any changes annually:
Any addendums to the Infection Control Plan, Designation of Facility Responsibility (LIC308), Personnel Report (LIC500) to include the Administrator presence in the facility, Administrator Certificate-Updated, Affidavit Regarding Client/Resident Cash Resources (LIC400), Surety Bond (LIC402), Emergency Disaster Plan (LIC610D), Administrative Organization (LIC309), Control of Property

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 6, no deficiencies are being cited
An exit interview was conducted, a copy of the report was given.
SUPERVISORS NAME: Victoria Brown
LICENSING EVALUATOR NAME: Victoria Brown
LICENSING EVALUATOR SIGNATURE: DATE: 10/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/14/2023
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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