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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 419210045
Report Date: 12/15/2023
Date Signed: 12/15/2023 05:20:14 PM

Document Has Been Signed on 12/15/2023 05:20 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
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:LOLA'S HOMEFACILITY NUMBER:
419210045
ADMINISTRATOR:ADAM CANONFACILITY TYPE:
735
ADDRESS:2956 FLEETWOOD DRIVETELEPHONE:
(650) 873-3530
CITY:SAN BRUNOSTATE: CAZIP CODE:
94066
CAPACITY: 4CENSUS: 4DATE:
12/15/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
04:20 PM
MET WITH:Caregiver, Ryan IlustrisimoTIME COMPLETED:
05:30 PM
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On 12/15/2023, Licensing Program Analyst (LPA) Murial Han conducted an unannounced Case Management Health Checks visit due to an incident that was reported by the facility on 11/20/2023. LPA met with caregiver, Ryan Ilustrisimo and explained the purpose of the visit. Former administrator, Leonardo De La Cruz arrived at the facility during the visit and assisted with the rest of the visit.

LPA toured the facility with caregiver and observed facility to be cleaned and tidy. The indoor and outdoor passageways were free of obstructions. The medication and sharps are stored in the kitchen and observed to be locked and inaccessible to clients. 2-day perishable and 7-day non-perishable was observed. Living room was free from tripping hazards. A comfortable temperature is maintained and lighting is sufficient for comfort.

LPA toured the garage and observed additional food supply. Washer and dryer was observed to be in working condition and in good repair. Chemicals and toxins were observed in the locked cabinets in the garage.

During today's visit, there are 2 clients present both of them appeared to be calm, comfortable and well-groomed.

No deficiencies observed during this visit. LPA reviewed report with former administrator and a copy is provided.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE: DATE: 12/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/12/2023
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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