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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 419210112
Report Date: 10/28/2023
Date Signed: 10/28/2023 01:18:14 PM

Document Has Been Signed on 10/28/2023 01:18 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
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:ELENA'S HOMEFACILITY NUMBER:
419210112
ADMINISTRATOR:LYNDON M GANIRFACILITY TYPE:
735
ADDRESS:1075 17TH AVENUETELEPHONE:
(650) 454-9905
CITY:REDWOOD CITYSTATE: CAZIP CODE:
94063
CAPACITY: 4CENSUS: 3DATE:
10/28/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:TIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Jason Lund arrived unannounced to conduct an annual/required inspection. LPA met with staff and later with Administrator Lyndon Ganir and explained the reason for the visit. Census:3

LPA Lund toured/inspected the facility inside and outside. Pathways were observed to be free of obstruction and fire hazards. The facility's fire clearance was approved for 4 ambulatory clients two (2) of which may be non-ambulatory in Rooms #1 & 2 only. Lan line phone. Centrally stored medications were locked in a cabinet underneath the kitchen counter. Sharp objects were locked in the kitchen cabinet next to the stove. Toxic chemicals were locked inside the garage. LPA observed there was at least 7 days of nonperishable and 2 days of perishable foods. Facility room temperature was maintained at 73 degrees Fahrenheit. Client's bathrooms have paper towels, grab bars and a non-skid tiled floor. Last Fire drill was conducted on 8/25/23 which staff/clients practice every three (3) months. Fire extinguisher was fully charged and last inspected on 8/19/23. Dual Smoke & Carbon monoxide detectors were operational.

LPA reviewed two (2) clients and two (2) staff files. Staff had criminal record clearances to work and are associated to the facility. Clients records all contain SFRC Admission Agreements, medical assessments, needs and service plans/appraisals, Consent forms, SFRC Individual Service Plans (ISPs) and Individual Program Plans (IPPs), Behaviorist reports. The facility has potentially dangerous objects locked and inaccessible to clients in care. P&I monies were reviewed and observed to match records as well as kept secure/intact from other facility funds.

No deficiencies were observed in the areas that were evaluated. No citations were issued during today’s inspection.

Exit interview conducted with Administrator Lyndon Ganir and a copy of this report provided.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE: DATE: 10/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/28/2023
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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