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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 419210053
Report Date: 01/16/2025
Date Signed: 01/16/2025 03:50:43 PM

Document Has Been Signed on 01/16/2025 03:50 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:CHANZE ADULT RESIDENTIAL FACILITYFACILITY NUMBER:
419210053
ADMINISTRATOR/
DIRECTOR:
MARIMIL, SANTOSFACILITY TYPE:
735
ADDRESS:1112 SUNNYSIDE DRIVETELEPHONE:
(650) 291-5330
CITY:SOUTH SAN FRANCISCOSTATE: CAZIP CODE:
94080
CAPACITY: 3CENSUS: 3DATE:
01/16/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:20 PM
MET WITH:Ramon De Los SantosTIME VISIT/
INSPECTION COMPLETED:
04:05 PM
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On 1/15/2025 LPA Grace Donato made an unannounced annual visit to the facility. LPA met with Home Manager Ramon De Los Santos and explained the purpose of the visit..

LPA toured the facility inside and outside including all of resident rooms, garage, and kitchen area. All residents are arriving from day program one by one. 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 110 deg F. The facility is observed to be clean, odorless, and well maintained. Residents bedrooms were observed to be well organized and fully furnished with adequate lighting. Sharps and toxic materials were observed locked and inaccessible to residents. First aid kit was complete. LPA checked the food supply and there is adequate amount of food, 2 days for perishables and & 7 days non-perishable. Carbon monoxide/ smoke detectors, and fire extinguisher were present throughout the facility. Facility has an updated log for emergency drill will is done every month.

Three resident records and three staff records were reviewed. Resident records are updated, complete and signed. Staff records are complete, with training logs. Staff have current First Aid/CPR certifications on file.

Centrally stored medication was locked in the office cabinet and inaccessible to residents. All medication logs are complete and updated.

No deficiencies being cited today. Report is reviewed and copy is provided.
SUPERVISORS NAME: Andrea Medlin
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE: DATE: 01/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/16/2025
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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