<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 419210112
Report Date: 06/07/2024
Date Signed: 06/07/2024 11:10:37 AM

Document Has Been Signed on 06/07/2024 11:10 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: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: 3DATE:
06/07/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:40 AM
MET WITH:Administrator - Lyndon GanirTIME VISIT/
INSPECTION COMPLETED:
11:15 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 06/07/2024, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced case management - health and safety check. LPA met with administrator Lyndon Ganir and explained the purpose of today's visit.

There are currently 2 staff on duty and 1 resident is present. This facility provides 1:1 care per Lyndon. LPA made observations around the facility. LPA observed 1 resident in the living room adjacent to kitchen sitting in a chair. 2 other residents are in their day programs. Lunch is being cooked. LPA did not see any concerning items to note regarding the residents in care's health and safety or staff on duty. Resident present did not appear to be in distress. Resident allowed LPA to observe their room and was interacting with staff and LPA, and responsive when spoken to.

Report is reviewed with Lyndon. Copy is provided.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Jaime Vado
LICENSING EVALUATOR SIGNATURE: DATE: 06/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/07/2024
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 1