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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 419210070
Report Date: 03/04/2024
Date Signed: 03/04/2024 11:51:06 AM

Document Has Been Signed on 03/04/2024 11:51 AM - 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:SVS DALY CITY SKILLS CENTERFACILITY NUMBER:
419210070
ADMINISTRATOR:ALEJANDRA DUENASFACILITY TYPE:
775
ADDRESS:312 90TH STREETTELEPHONE:
(650) 757-4977
CITY:DALY CITYSTATE: CAZIP CODE:
94015
CAPACITY: 60CENSUS: 45DATE:
03/04/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Alejandra DuenasTIME COMPLETED:
12:15 PM
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On 3/4/2024 LPA Grace Donato made an unannounced annual visit to the facility. LPA met with Program Director Alejandra Duenas. LPA explained the purpose of the visit.

LPA toured the facility including all of activity rooms, common areas & kitchen. The indoor and outdoor passageways were free of obstruction. LPA observed clients doing activities such as arts & crafts, watching movies. 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. Facility has a sprinkler system. All fire extinguishers have been checked and current. Client bathrooms were observed to be in good repair. Changing rooms are equipped with changing tables and supply of incontinent items. Food are brought in by residents prepared from their home facilities. Emergency drills are done monthly. Medications are not administered in the facility.

Five client records and five staff records were reviewed. Resident records are updated, complete and signed. Staff records are complete, with training logs.

LPA requested these documents from facility: LIC 500.

No deficiencies are cited at this time. Report is reviewed and a copy is provided.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE: DATE: 03/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/04/2024
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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