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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 419210112
Report Date: 04/24/2024
Date Signed: 04/24/2024 04:24:37 PM

Document Has Been Signed on 04/24/2024 04:24 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:ELENA'S HOMEFACILITY NUMBER:
419210112
ADMINISTRATOR/
DIRECTOR:		LYNDON M GANIRFACILITY TYPE:
735
ADDRESS:1075 17TH AVENUETELEPHONE:
(650) 454-9905
CITY:REDWOOD CITYSTATE: CAZIP CODE:
94063
CAPACITY: 4CENSUS: 4DATE:
04/24/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Rachel Belong, Direct Support Professional, Lyndon Ganir, Administrator, and Enrico Dale, Direct Support ProfessionalTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
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On April 24, 2024 at 2:00 PM, Licensing Program Analyst(LPA) John Calandra arrived at the facility to complete the Annual 1-year required inspection. LPA Calandra was greeted by Enrico Dale, Direct Support Professional(DSP) and explained the purpose of his visit. Lyndon Ganir, Administrator and Rachel Belong, Direct Support Professional arrived later during the visit.

LPA Calandra reviewed Personal and Incidental (P & I) money and records. All P&I money was accounted for and matched the records kept on site.

A review of Centrally stored medications indicated that medications for residents were properly labeled with instructions on dosage and times of day and matched the Centrally Stored Medication Records(CSMR) kept at the facility.

LPA Calandra also reviewed 6 staff records and 4 client records. All were observed to be complete.

No deficiencies were cited during today's visit.

This report was reviewed with Lyndon Ganir, Administrator and a copy of the report left at the facility.

SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: John Calandra
LICENSING EVALUATOR SIGNATURE: DATE: 04/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/24/2024
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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