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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 419210059
Report Date: 10/15/2024
Date Signed: 10/15/2024 04:18:35 PM

Document Has Been Signed on 10/15/2024 04:18 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:SAN FELIPE HOUSEFACILITY NUMBER:
419210059
ADMINISTRATOR/
DIRECTOR:
THESS T. NOVICIOFACILITY TYPE:
735
ADDRESS:221 SAN FELIPE AVENUETELEPHONE:
(650) 634-8648
CITY:SOUTH SAN FRANCISCOSTATE: CAZIP CODE:
94080
CAPACITY: 6CENSUS: 6DATE:
10/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:46 PM
MET WITH:Editha SantosTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
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On 10/15/2024, LPA Grace Donato made an unannounced annual visit to the facility. LPA met with Administrator Editha Santos. LPA explained the purpose of the visit.

LPA toured the facility including common areas & laundry rooms, bathrooms, and shower rooms. The indoor and outdoor passageways were free of obstruction. There is a shed at the back used for storage. LPA observed residents arriving from day programs. Hot water was also tested in the bathrooms and the temperature was 109 deg F. The residents have adequate amount of linens in their bedrooms. All personal belongings are intact. Resident bedrooms and bathrooms were observed to be in good repair. Bathrooms and shower rooms are equipped with grab bars and non-skid floors. Sharps and toxic materials were observed locked and inaccessible to residents. Food supply in was observed with an adequate two day perishable and seven day non-perishable food supply. Carbon monoxide monitor is working and fire extinguisher were present throughout the facility.

Six resident records and five staff records were reviewed. Resident records are updated, complete and signed. Staff records have health screening with TB test information, medication training and up to date First Aid/CPR Certification.

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

LPA requested the following documents to be emailed: LIC308, LIC500, Surety Bond & Lease Agreement,

No deficiencies are cited at this time. Report is reviewed and a copy is provided.
SUPERVISORS NAME: Andrea Medlin
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE: DATE: 10/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/15/2024
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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