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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 419210045
Report Date: 11/15/2023
Date Signed: 11/15/2023 04:59:51 PM

Document Has Been Signed on 11/15/2023 04:59 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
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:LOLA'S HOMEFACILITY NUMBER:
419210045
ADMINISTRATOR:JESIELYN JOY ALICAWAYFACILITY TYPE:
735
ADDRESS:2956 FLEETWOOD DRIVETELEPHONE:
(650) 873-3530
CITY:SAN BRUNOSTATE: CAZIP CODE:
94066
CAPACITY: 4CENSUS: 4DATE:
11/15/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Administrator, Adam Canon TIME COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Jason Lund arrived unannounced to conduct an annual/required visit. LPA met Administrator, Adam Canon and explained the reason for the visit. Census: 4

LPA Lund & Administrator Adam Canon toured/inspected the facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water. A comfortable temperature for clients is maintained at 73 degree Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the clients. All toilets, hand washing and bathing are safe, sanitary and in operating condition.

Smoke detectors, carbon monoxide & fire extinguirshers were in operating condition during visit. Emergency Disaster Drill was last posted 08/19/2023. First aid kit was observed to be complete.

LPA reviewed 4 staff records and 4 of 4 staff are associated to the facility and have current first aid training. LPA reviewed 2 clients records and 4 of 4 clients have current Needs and Services Plan. LPA reviewed 2 of 4 client's medications.

Facility is in compliance during visit. No deficiencies were cited during this inspection. Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE: DATE: 11/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/15/2023
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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