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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415201932
Report Date: 05/03/2024
Date Signed: 05/03/2024 01:39:33 PM


Document Has Been Signed on 05/03/2024 01:39 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:ATENAR HOME, INC.FACILITY NUMBER:
415201932
ADMINISTRATOR:MARJORIE ONGPAUCOFACILITY TYPE:
734
ADDRESS:680 EDNA WAYTELEPHONE:
(650) 315-2170
CITY:SAN MATEOSTATE: CAZIP CODE:
94402
CAPACITY:4CENSUS: 4DATE:
05/03/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Edna Flores and Nemia AtendidoTIME COMPLETED:
01:45 PM
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LPA Audrey Jeung toured facility and grounds. There are 4 private client bedrooms, 2 full bathrooms, dining/living area and kitchen. Washer and dryer are located in attached 1-car garage. The paved yard is enclosed by wood fence. No accessible bodies of water or fire safety hazards are observed. PPE and food supplies--including liquid formula for G-tube feeding--is adequate. Medications, toxins and sharps are stored appropriately and inaccessible to clients, a comfortable temperature is maintained, and lighting is sufficient for comfort and safety. Hot water temperature tested at 107 degrees F in client bathroom. Soap and paper towels are present in bathrooms and kitchen sink. First-aid kit is inspected and complete. A Disaster and Mass Casualty Plan is accessible to staff. There are no residents present.
Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed, as well as staff records. Marjorie Ongpauco is a certified ARF administrator (x4/25) that oversees facility operations of this Adult Residential Facility for Persons with Special Health Care Needs.
Client records are reviewed, and medications are recorded on Centrally Stored Medications Records.
All clients' beds have 2 half bed rails, for which facility was granted a waiver.

The following forms/information are requested to be updated and submitted to LPA by 5/17/24:

• LIC 308 Designation of Administrative Responsibility
• LIC 309 Administrative Organization
• LIC 610 Emergency Disaster Plan


Copy of Personnel Report (LIC500) and proof of current Surety Bonding are provided to LPA today.

No deficiencies of the General Licensing Regulations, of the California Code of Regulations, Title 22, Division 6, are observed. See Advisory Notes--2 pages--for technical violations.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:
DATE: 05/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/03/2024
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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