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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 419210095
Report Date: 09/15/2023
Date Signed: 09/15/2023 06:30:18 PM

Document Has Been Signed on 09/15/2023 06:30 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
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:HORIZON ADULT DAY PROGRAMFACILITY NUMBER:
419210095
ADMINISTRATOR:MARIBETH LUCEROFACILITY TYPE:
775
ADDRESS:3500 CALLAN BLVD.,STE. 100&101TELEPHONE:
(650) 952-5165
CITY:SOUTH SAN FRANCISCOSTATE: CAZIP CODE:
94080
CAPACITY: 45CENSUS: 34DATE:
09/15/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Alona PobleteTIME COMPLETED:
01:10 PM
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On 9/15/23 LPA Grace Donato made an unannounced annual visit to the facility. LPA met with Program Supervisor, Alona Poblete. LPA explained the purpose of the visit.

LPA toured the facility inside and outside 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 & music therapy. While touring the facility it was observed that the room temperature was at 71 deg F. Hot water was also tested in the bathrooms and the temperature was 110 deg F. Carbon monoxide monitors are working properly. All fire extinguishers have been checked and current. Client bathrooms were observed to be in good repair equipped with grab bar, changing tables and non-skid floors. Food are brought in by residents prepared from their home facilities. Snacks are provided. Chemicals are in a locked space. No medication in the facility.

Three client records and three staff records were reviewed. Resident records are updated, complete and signed. Staff records are complete, with training logs. Facility has a certified administrator on site with complete certification and training requirements. LPA attempted to interview 3 clients. LPA also interviewed 3 staff members.

LPA requested licensee to submit the following and was received in the facility at 9/15/23:
LIC 500 Personnel Report, Lease, Infection Control Plan, LIC 610D.

No deficiencies are cited at this time. Report is reviewed and a copy is provided.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE: DATE: 09/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/15/2023
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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