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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 419210115
Report Date: 10/28/2023
Date Signed: 10/28/2023 03:45:43 PM

Document Has Been Signed on 10/28/2023 03:45 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:AVENUE HOME, THEFACILITY NUMBER:
419210115
ADMINISTRATOR:RAQUEL MAGDALENOFACILITY TYPE:
735
ADDRESS:1165 MARSH ROADTELEPHONE:
(650) 362-4246
CITY:REDWOOD CITYSTATE: CAZIP CODE:
94063
CAPACITY: 4CENSUS: 4DATE:
10/28/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Administrator Osyuki Reyes TIME COMPLETED:
04:00 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 Osyuki Reyes and explained the purpose of the visit. Census: 4

LPA Lund & Administrator Osyuki Reyes toured/inspected the facility and grounds. No accessible bodies of water or fire safety hazards observed. Medications, toxins and sharps are stored appropriately and inaccessible to clients, a comfortable temperature is maintained, and lighting is sufficient for comfort and safety. Soap and paper towels are present in bathrooms and kitchen sink. First-aid kit is inspected and complete. LPA observed there was at least 7- days of nonperishable and 2- days of perishable foods. Facility room temperature was maintained at 71 degrees Fahrenheit. Client's bathrooms have paper towels, grab bars and a non-skid tiled floor. Last Fire drill was conducted on 10/4/23 which staff/clients practice every three (3) months. Fire extinguisher was fully charged and last inspected on 8/24/23. Dual Smoke & Carbon monoxide detectors were operational.

LPA reviewed two (2) clients and four (4) 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 deficiency cited today. This report is reviewed and discussed with the lead staff and a copy is 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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