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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 419210116
Report Date: 07/23/2024
Date Signed: 07/23/2024 08:17:45 PM

Document Has Been Signed on 07/23/2024 08:17 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:SANGHA HOUSEFACILITY NUMBER:
419210116
ADMINISTRATOR/
DIRECTOR:
SALLY DELA CUEVAFACILITY TYPE:
735
ADDRESS:3640 FLEETWOOD DRIVETELEPHONE:
(650) 515-4083
CITY:SAN BRUNOSTATE: CAZIP CODE:
94066
CAPACITY: 4CENSUS: 4DATE:
07/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:00 PM
MET WITH:Administrator, Sally De La CuevaTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
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On July 23, 2024, Licensing Program Analyst(LPA) Murial Han conducted an unannounced annual inspection. LPA was greeted by the administrator, Sally De La Cueva and explained the purpose of today's visit.

LPA toured facility and grounds. No accessible bodies of water or fire safety hazards observed. LPA toured the facility inside and outside including all of resident rooms, common areas, and kitchen area. The indoor and outdoor passageways were free of obstruction. Facility was overall clean and odor-free. Comfortable temperature is maintained and lighting is sufficient for comfort.

LPA observed four private resident rooms. Rooms were spacious and included all required furnishings. Two full bathrooms were observed to be clean and in operating condition. Hot water temperature was measured at 106 F.

LPA observed medications, toxins and sharps to be locked and inaccessible to residents in care. 2 days for perishables and & 7 days non-perishable were observed to be present.

Emergency drill records were reviewed.

A review of (4) resident files was conducted and noted on the LIC 858.
A review of (4) staff files was conducted and noted on the LIC 859.

LPA reviewed P& I records for 4 residents to be adequate.

No deficiency cited today.

This report is reviewed and discussed with the administrator. A copy is provided.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE: DATE: 07/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/23/2024
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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