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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 419210054
Report Date: 02/10/2025
Date Signed: 02/10/2025 04:37:30 PM

Document Has Been Signed on 02/10/2025 04:37 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:CARMELINA'S HOMEFACILITY NUMBER:
419210054
ADMINISTRATOR/
DIRECTOR:
JESSICA PAULEFACILITY TYPE:
735
ADDRESS:740 PALM AVENUETELEPHONE:
(650) 989-8629
CITY:SOUTH SAN FRANCISCOSTATE: CAZIP CODE:
94080
CAPACITY: 3CENSUS: 3DATE:
02/10/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:08 PM
MET WITH:Jessica Paule & Eliodoro PenaTIME VISIT/
INSPECTION COMPLETED:
04:45 PM
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On 2/10/2025, LPA Grace Donato made an unannounced annual visit to the facility. LPA met with Administrator Jessica Paule & Lead Staff Eliodoro Pena and LPA explained the purpose of the visit

LPA toured the facility inside and outside including all of resident rooms, garage, and kitchen area. LPA observed one resident in the facility. While touring the facility it was observed that the room temperature was at 69 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. Rooms have alarms on the windows and exit door. Sharps and toxic materials were observed locked and inaccessible to residents. Food supply in kitchen was observed with an adequate two day perishable and seven day non-perishable food supply. Carbon monoxide/ smoke detectors, and fire extinguisher were present throughout the facility. Facility has an updated log for emergency drill will is done quarterly.

Three resident records and three staff records were reviewed. Centrally stored medication was locked and inaccessible by residents. All medication was labeled and sorted by resident name. All medication logs are complete and updated.

LPA received the following documents: LIC500, Staff Schedule & Administrator Certificate. Facility will email copy of Control of Property.
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No deficiencies cited today. Report is reviewed and copy is provided.
SUPERVISORS NAME: Andrea Medlin
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE: DATE: 02/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/10/2025
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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