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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202751
Report Date: 01/20/2024
Date Signed: 01/20/2024 01:47:33 PM


Document Has Been Signed on 01/20/2024 01:47 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
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FACILITY NAME:EPIONE RESIDENTIAL CAREFACILITY NUMBER:
435202751
ADMINISTRATOR:JACOBS, LILIBETH P.FACILITY TYPE:
740
ADDRESS:1212 S MARY AVETELEPHONE:
(408) 746-5605
CITY:SUNNYVALESTATE: CAZIP CODE:
94087
CAPACITY:6CENSUS: 6DATE:
01/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Lilibeth JacobsTIME COMPLETED:
02:10 PM
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On 1/20/24, Licensing Program Analyst (LPA) M. Medina conducted an unannounced Annual Required Inspection. LPA introduced self, stated purpose of visit, and allowed entrance by Licensee Lilibeth Jacobs. Lilibeth Jacobs also serves as facility Administrator, #6050851740 expires 1/15/2025.

There are currently six (6) residents in care. Five (5) residents were present during today's inspection. Residents were observed to be visiting with family, and relaxing in their bedrooms.

Facility tour conducted with licensee. Facility has all private bedrooms. Facility observed to be in good repair, well lit, have adequate seating in all common areas, comfortable temperature, and to be odor free. All resident bedrooms observed to be fully furnished. Bathrooms toured, showers observed to have shower chairs, grab bars, and non-skid mats available. Toilet area also observed to have grab bars. Water temperature measured in bathroom at 116 degrees F. Kitchen toured, facility observed to have adequate food supply for residents in care. All sharps observed to be locked and secured in kitchen drawer. Cleaning supplies in kitchen cabinet are locked, secured, and inaccessible to residents. Garage is utilized as laundry room and additional storage, observed to be locked, secured, and inaccessible to residents. Medications observed to be locked and secured in dining room cabinet.

Fire extinguisher present with a purchase date of 11/06/23. Carbon monoxide detector and smoke detector observed operational during inspection. Facility is also equipped with a pull station. Last fire drill conducted on 12/17/23 according to facility records.

Outside of facility toured. No obstructions or hazards observed.

The following documents were submitted to San Bruno Regional Office in 9/2023:
LIC 500, LIC 308, LIC 400, LIC 610E, LIC 503 for staff, copy of Administrator Certificate and copy of Liability Insurance. LPA received updated copy of LIC 9020 during facility inspection.

No deficiencies observed during inspection.
SUPERVISOR'S NAME: Brenda WhiteTELEPHONE: (559) 243-8080
LICENSING EVALUATOR NAME: Melinda MedinaTELEPHONE: (559) 650-7904
LICENSING EVALUATOR SIGNATURE:
DATE: 01/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/20/2024
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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