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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 419210106
Report Date: 07/11/2024
Date Signed: 07/12/2024 11:15:08 AM

Document Has Been Signed on 07/12/2024 11:15 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:FENIX HOMEFACILITY NUMBER:
419210106
ADMINISTRATOR/
DIRECTOR:
LILIBETH LETRONDOFACILITY TYPE:
735
ADDRESS:437 FERNDALE AVETELEPHONE:
(650) 580-1266
CITY:SOUTH SAN FRANCISCOSTATE: CAZIP CODE:
94080
CAPACITY: 4CENSUS: 4DATE:
07/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:48 PM
MET WITH:Susan Davo & Josef RapadasTIME VISIT/
INSPECTION COMPLETED:
03:15 PM
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*** This is an amended report ***

On 7/11/24, LPA Grace Donato made an unannounced annual visit to the facility. LPA met with Co-Administrator, Josef Rapadas & Lead Staff, Susan Davo and LPA explained the purpose of the visit

LPA toured the facility inside and outside including all of resident rooms, garage, and kitchen area. LPA observed all residents resting in their bedrooms. Residents are currently in day program. While touring the facility it was observed that the room temperature was at 74 deg F. Hot water was also tested in the bathrooms and the temperature was 108 deg F. The facility is observed to be clean, odorless, and well maintained. Residents bedrooms were observed to be well organized and fully furnished with adequate lighting. Sharps and toxic materials were observed locked in the kitchen cabinet and underneath the sink and inaccessible to residents. Food supply in kitchen and garage freezer was observed with an adequate two day perishable and seven day non-perishable food supply. Carbon monoxide/ smoke detectors, and fire extinguisher were present throughout the facility. Facility has an updated log for emergency drill is done every quarter.

Four resident records and five staff records were reviewed. Resident’s PNI money was counted and all accounted for with proper log and receipts. Centrally stored medication was locked and inaccessible by residents. All medication was labeled and sorted by resident name. All medication logs are complete and updated.

LPA received the following documents: LIC308, Control of Property, Staff Schedule & Administrator Certificate.
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No deficiencies cited today. Report is reviewed and copy is provided.
SUPERVISORS NAME: Andrea Medlin
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE: DATE: 07/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/12/2024
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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