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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803428
Report Date: 09/17/2024
Date Signed: 09/17/2024 02:54:44 PM

Document Has Been Signed on 09/17/2024 02:54 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:MUIR WOOD LLC - SKILLMAN SOUTHFACILITY NUMBER:
496803428
ADMINISTRATOR/
DIRECTOR:		PAEZ AZEVEDO,KELLIFACILITY TYPE:
730
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 10CENSUS: 6DATE:
09/17/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:15 PM
MET WITH:Kelli Azevedo, Operations DirectorTIME VISIT/
INSPECTION COMPLETED:
03:15 PM
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On 9-17-24 12:15PM, Licensing Program Analysts George Karkazis conducted an unannounced Annual/Random inspection at listed facility. LPA met with Kelli Azevedo, Operations Director, and toured the facility inside and out. The Group Home is licensed to serve 10 clients. Present during the inspection were 2 staff and 1 client.

At 12:25PM LPA Karkazis reviewed client and staff files. All staff and client files were complete and in good order.

At 2:15PM, LPA Karkazis toured the facility. LPA Karkazis observed 3 bedrooms and 4 bathrooms. LPA observed facility license, personal rights, facility sketch, meal menu, and other forms posted on the walls throughout the facility. LPA Karkazis tested the water temperature and found it to be 113 degrees which is in range. The thermostat read 71 which is within range. Sharps were locked and chemicals were safely stored. There were two days of perishable foods and seven days non-perishable foods present. The medication was also stored and locked in the medications room in locked cabinet. The facility is in good repair and clean. LPA Karkazis interviewed 2 staff and 1 client.

At 2:35PM, LPA Karkazis toured the backyard. There were no open bodies of water. The backyard was in good repair and clean. At this time there were no deficiencies

An exit interview was conducted, appeal rights discussed and a copy of this report was given to Kelli Azevedo.
NAME OF LICENSING PROGRAM MANAGER: Isabel Diego
NAME OF LICENSING PROGRAM ANALYST: George Karkazis
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/17/2024
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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