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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 419210105
Report Date: 03/12/2025
Date Signed: 03/12/2025 04:10:34 PM

Document Has Been Signed on 03/12/2025 04:10 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:FOCUS DAY PROGRAM IIIFACILITY NUMBER:
419210105
ADMINISTRATOR/
DIRECTOR:		YOLANDA T. RUIZFACILITY TYPE:
775
ADDRESS:755 CALIFORNIA DRIVETELEPHONE:
(650) 347-4780
CITY:BURLINGAMESTATE: CAZIP CODE:
94010
CAPACITY: 75CENSUS: 37DATE:
03/12/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Manager, Jaime OrtizTIME VISIT/
INSPECTION COMPLETED:
11:30 AM
NARRATIVE
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On March 12, 2025, Licensing Program Analyst (LPA) Murial Han 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 observed staff are encouraging residents with participating in activities.

LPA toured the facility activity rooms, nurse room, conference room, and kitchen area. LPA observed 5 facility bathrooms to be clean and odor free. Hot water temperature was measured at 109- 110 degrees F. A comfortable temperature is maintained and lighting is sufficient for comfort.

Kitchen was observed to be clean and free from flies and pests.

Clients belongings/lunches were observed to be stored on shelved in the activity room and, facility staff will prepare their lunches and pass them out at lunch time. Facility has a licensed professional who assists with medications and glucose monitoring 5 days a week.

Fire extinguishers were last inspected in 6/2024.

A review of (5) client files were conducted and noted on the LIC 858.
A review of (5) staff files was conducted and noted on the LIC 859.

Deficiency of the California Code of Regulations, Title, 22 cited on the LIC 809D. Failure to correct the deficiencies may result in civil penalties.

This report is reviewed and discussed with the supervisor.

A copy of this report and appeal rights were provided.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE: DATE: 03/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/12/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 03/12/2025 04:10 PM - It Cannot Be Edited


Created By: Murial Han On 03/12/2025 at 11:08 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: FOCUS DAY PROGRAM III
FACILITY NUMBER: 419210105

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/12/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82068(a)
Admission Agreements
(a) The licensee shall complete and maintain an individual written admission agreement with each client and the client's authorized representative, if any.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as based on record reviews, observations and interviews 5 out of 5 resident admission agreements were incomplete due to lack of signature from the administrator/licensee which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/20/2025
Plan of Correction
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The administrator/licensee will develop a plan to ensure compliance and will provide a copy of the completed admission agreement to CCL by 3/20/2025.
Type B
Section Cited
CCR
82069(a)
Client Medical Assessments
(a) Prior to or within 30 calendar days following the acceptance of a client, the licensee shall obtain a written medical assessment of the client that determines the licensee's ability to provide necessary health-related services to the client. The assessment shall be used in developing the Needs and Services Plan.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as based on observation, record reviews and interview 2 out of 5 residents did not have a copy of their medical assessment which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/20/2025
Plan of Correction
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The administrator/licensee will develop a plan to ensure compliance and will provide a copy of their medical assessment (LIC602) to CCL by 3/20/2025.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:April Cowan
LICENSING EVALUATOR NAME:Murial Han
LICENSING EVALUATOR SIGNATURE:
DATE: 03/12/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/12/2025


LIC809 (FAS) - (06/04)
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