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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 419210053
Report Date: 10/09/2023
Date Signed: 10/09/2023 03:56:18 PM

Document Has Been Signed on 10/09/2023 03:56 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:CHANZE ADULT RESIDENTIAL FACILITYFACILITY NUMBER:
419210053
ADMINISTRATOR:MARIMIL, SANTOSFACILITY TYPE:
735
ADDRESS:1112 SUNNYSIDE DRIVETELEPHONE:
(650) 291-5330
CITY:SOUTH SAN FRANCISCOSTATE: CAZIP CODE:
94080
CAPACITY: 3CENSUS: 3DATE:
10/09/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:38 PM
MET WITH:Ramon SantosTIME COMPLETED:
04:00 PM
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On 10/9/23 LPA Grace Donato made an unannounced annual visit to the facility. LPA met with Administrator Ramon Santos. LPA explained the purpose of the visit.

LPA toured the facility inside and outside including all of resident rooms, common areas, kitchen & garage. The indoor and outdoor passageways were free of obstruction. Two residents have just arrived from adult day program. The residents have adequate amount of linens and incontinence care items. All personal belongings are intact. While touring the facility it was observed that the room temperature was at 69 deg F. Hot water was also tested in the bathrooms and the temperature was 112 deg F. Carbon monoxide monitor is working properly. All fire extinguishers have been checked and current. Client bathrooms were observed to be in good repair equipped with grab bars and non-skid mats. LPA checked the food supply and there is adequate amount of food, 2 days for perishables and & 7 days non-perishable. Emergency drills are logged and done every month.

Three client records and two staff records were reviewed. Resident records are updated, complete and signed. Staff records are complete, with training logs. Facility has a certified administrator on site with complete certification and training requirements. LPA attempted to interview two residents. LPA also interviewed two staff members.

Medication review was done, and all medications are accounted for, and centrally stored medication records are updated.

LPA requested documents: LIC 308, LIC 610D, LIC 500, Certificate of Liability Insurance & Surety Bond.

No deficiencies are cited at this time. Report is reviewed and a copy is provided.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE: DATE: 10/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/09/2023
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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