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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 419210105
Report Date: 09/08/2023
Date Signed: 09/08/2023 12:40:45 PM

Document Has Been Signed on 09/08/2023 12:40 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:FOCUS DAY PROGRAM IIIFACILITY NUMBER:
419210105
ADMINISTRATOR:YOLANDA T. RUIZFACILITY TYPE:
775
ADDRESS:755 CALIFORNIA DRIVETELEPHONE:
(650) 347-4780
CITY:BURLINGAMESTATE: CAZIP CODE:
94010
CAPACITY: 75CENSUS: 54DATE:
09/08/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Program Manager, Jaime OrtizTIME COMPLETED:
12:55 PM
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On September 8, 2023, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced annual inspection. LPA met with Program Manager, Jaime Ortiz and Program Supervisor, Miguelito Macam and explained the purpose of the visit.

LPA toured facility and grounds. No accessible bodies of water or fire safety hazards observed. During the visit, LPA observed day program clients to be split into 5 different groups with sufficient amount of staff members present in each group to assist clients.

LPA toured the facility inside including but not limited to facility activity rooms, conference room, and kitchen area. LPA observed 5 facility bathrooms to be clean and odor free and equipped with liquid soap and paper towels. LPA observed nurse's room which has a changing station. There is a total of 2 changing station located in the facility. Kitchen was observed to be clean and free from flies and pests. According to Program Manager, clients are able to utilize the kitchen fridge for their lunches. Clients belongings were observed to be stored on shelved in the activity room.

Toxins, cleaning supplies, and sharps are observed to be locked and inaccessible to clients in care. Smoke and carbon monoxide detectors were observed as operational. Fire extinguisher was last inspected on 3/2023. First aid kit was observed to be complete.

At 11:45AM, LPA reviewed 8 clients files and 6 staff files. LPA observed all files to be complete and up-to-date. The facility has 8 vans to transport clients. The vehicles are being checked quarterly.

No deficiencies are issued during the visit. LPA reviewed report with Program Manager and Program Supervisor and a copy is provided.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE: DATE: 09/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/08/2023
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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