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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 419210115
Report Date: 05/06/2024
Date Signed: 05/06/2024 05:49:07 PM

Document Has Been Signed on 05/06/2024 05:49 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
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:AVENUE HOME, THEFACILITY NUMBER:
419210115
ADMINISTRATOR/
DIRECTOR:		OSYUKI R. HERRERAFACILITY TYPE:
735
ADDRESS:1165 MARSH ROADTELEPHONE:
(650) 362-4246
CITY:REDWOOD CITYSTATE: CAZIP CODE:
94063
CAPACITY: 4CENSUS: 4DATE:
05/06/2024
TYPE OF VISIT:Required - 1 YearANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:45 PM
MET WITH:AshleyTIME VISIT/
INSPECTION COMPLETED:
06:00 PM
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LPA Jeung toured facility and grounds, including detached accessory dwelling unit (ADU)--used for storage--and attached 1-car garage, where washer and dryer are located. This one level facility consists of four private client bedrooms, office, 2 common bathrooms, kitchen, and living/dining area. There are no accessible bodies of water or fire safety hazards observed. Medications, toxins and sharps are stored appropriately and inaccessible to clients, and a comfortable temperature is maintained. Operable carbon monoxide detectors are present. Hot water temperature is tested at 107 degrees F. Food and PPE supplies and first-aid kit are inspected. Client files are reviewed, including medications for two residents that are recorded on Centrally Stored Medications Record. A Disaster and Mass Casualty Plan is posted.

Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed, as well as staff records. Osyuki Reyes-Herrera is a certified ARF administrator (x 9/25) that oversees facility operations.

The following forms/information are requested to be updated and returned to CCL by 5/20/24:

• LIC 309 Administrative Organization
• Proof of current surety bonding
• LIC 999 Facility Sketch (of property grounds, including ADU) and approved building permit
• Written notice--signed by licensee--to update email address

Deficiency of the ARF California Code of Regulations, Title 22, Division 6, Chapter 8 is observed and cited on a following page. See Advisory Notes-- 1page--for technical violation.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Audrey Jeung
LICENSING EVALUATOR SIGNATURE: DATE: 05/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/06/2024
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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Document Has Been Signed on 05/06/2024 05:49 PM - It Cannot Be Edited


Created By: Audrey Jeung On 05/06/2024 at 05:23 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: AVENUE HOME, THE
FACILITY NUMBER: 419210115

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85076(d)(1)
Food Service
(1) Supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days shall be maintained on the premises.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above, as facility maintains an insufficient supply of non-perishable fruits and vegetables for 4 residents. This poses a potential health, safety or personal rights risk to persons in care.
No canned fruits maintained, and only 1 can of green vegetables.
POC Due Date: 05/20/2024
Plan of Correction
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Receipt for purchase of 7-day supply of canned fruits and vegetables will be sent to CCLD BY DUE DATE.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Cara Smith
LICENSING EVALUATOR NAME:Audrey Jeung
LICENSING EVALUATOR SIGNATURE:
DATE: 05/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/06/2024


LIC809 (FAS) - (06/04)
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