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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 419210106
Report Date: 11/02/2022
Date Signed: 11/03/2022 12:16:17 PM

Document Has Been Signed on 11/03/2022 12:16 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:FENIX HOMEFACILITY NUMBER:
419210106
ADMINISTRATOR:LILIBETH LETRONDOFACILITY TYPE:
735
ADDRESS:437 FERNDALE AVETELEPHONE:
(650) 580-1266
CITY:SOUTH SAN FRANCISCOSTATE: CAZIP CODE:
94080
CAPACITY: 4CENSUS: 3DATE:
11/02/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
03:45 PM
MET WITH:Salvador Isberto and Lilibeth Letrondo RapadasTIME COMPLETED:
05:15 PM
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In response to Death Report dated 10/27/22, LPA Jeung toured facility, reviewed client files, and interviewed staff. There are 3 residents on site, and 3 staff. All residents receive regional center services. First-aid training for staff is confirmed and current. Copy of current Physician's Order for deceased client is obtained.

There are no health and safety violations observed today.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Audrey Jeung
LICENSING EVALUATOR SIGNATURE: DATE: 11/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/02/2022
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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