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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 419210070
Report Date: 07/17/2024
Date Signed: 07/17/2024 09:00:18 AM

Document Has Been Signed on 07/17/2024 09:00 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/
DIRECTOR:		ALEJANDRA DUENASFACILITY TYPE:
775
ADDRESS:312 90TH STREETTELEPHONE:
(650) 757-4977
CITY:DALY CITYSTATE: CAZIP CODE:
94015
CAPACITY: 60CENSUS: 48DATE:
07/17/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Administrator, Alejandra DuenasTIME VISIT/
INSPECTION COMPLETED:
09:10 AM
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On July 17, 2024, Licensing Program Analyst (LPA) Murial Han conducted an unannounced case management visit to follow-up on an incident that was reported by the facility. LPA met with the administrator and explained the purpose of today's visit.

On July 5, 2024, the facility reported that during an outing at Brisbane Pier, resident #1 (R1) climbed over the barrier of the pier and jump into the water. Staff #1 (S1) was with R1 and tried to stop R1 from jumping but was not successful, therefore, S1 jumped into to the water and attempted to rescue R1. Subsequently, both of them were saved by the Coast Guard and R1 was sent to the hospital, and R1 was released on the same day. R1 returned to the program a couple of days later.

According to the administrator, R1's responsible party stated that R1 is a great swimmer, loves the water and has a tendency of jumping into the water whenever he/she sees the water.

The administrator stated that there is no change with R1's participation level at the program since the incident and the facility is following the directive of R1's responsible party of not brining R1 to any outings with water around. In addition, the facility provided in-service to staff to prevent this from happening again.

During today's visit, LPA observed R1 to be calm, and participating in exercise of choice.

No deficiency cite today.

This report is reviewed with the administrator. A copy is provided.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE: DATE: 07/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/17/2024
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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