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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202589
Report Date: 02/12/2024
Date Signed: 02/12/2024 12:15:09 PM

Document Has Been Signed on 02/12/2024 12:15 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
Lookup Error,
, CA
FACILITY NAME:MUNA'S CARE HOME IIIFACILITY NUMBER:
435202589
ADMINISTRATOR:SEDIGH, TAYEBEHFACILITY TYPE:
735
ADDRESS:275 MORAGA WAYTELEPHONE:
(408) 856-5115
CITY:SAN JOSESTATE: CAZIP CODE:
95119
CAPACITY: 6CENSUS: 6DATE:
02/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:35 AM
MET WITH:Tayebeh SedighTIME COMPLETED:
12:25 PM
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On 2/12/2024, Licensing Program Analyst (LPA) M. Medina conducted an unannounced Annual Required inspection. LPA met with Licensee/Administrator, Tayebeh Sedigh.

Currently, six (6) residents in care. All residents were at day program at time of inspection. Facility inspection conducted with Licensee. Facility observed to be clean, odor free, and well lit. Adequate seating and lighting observed in both the living room and dining room. Resident bedrooms have all required accommodations. Resident bathrooms toured, LPA measured water temperature 120 degrees F. Kitchen toured, LPA observed a 2-day supply of perishable food and a 7-day supply of non-perishable food. All sharps observed to be locked and secured in kitchen drawer. Resident medications observed to be locked and secured in a cabinet in living room. Resident medications reviewed and observed to have original labels and to be administered as prescribed.

Smoke detectors observed to be operational during today's inspection. Carbon monoxide detector observed operational and mounted in the hallway near client bedrooms. Fire extinguishers present and has a service date of 3/23/2023. Last fire drill conducted on 2/03/2024 according to facility records. All chemicals are locked and secured in both the laundry room and in the garage.

Outside area toured. Yard is secured with a fence around the perimeter of yard. No hazards observed. Spa on patio is not in use and observed to have a locked cover in place. All fire exits open free of obstructions.

All facility staff who require caregiver background checks have received criminal record index clearance or exemptions. Staff and resident files reviewed.

Per Licensee, the following documents were requested and mailed to San Bruno Regional Office: LIC 200, LIC 308, LIC 400, LIC 500, copy of liability insurance and surety bond.

No deficiencies cited during today's inspection.
SUPERVISORS NAME: Brenda White
LICENSING EVALUATOR NAME: Melinda Medina
LICENSING EVALUATOR SIGNATURE: DATE: 02/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/12/2024
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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