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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
415600833
Report Date:
04/26/2024
Date Signed:
04/26/2024 03:39:11 PM
Document Has Been Signed on
04/26/2024 03:39 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
SAN BRUNO RO
,
851 TRAEGER AVE., SUITE 360
SAN BRUNO
,
CA
94066
FACILITY NAME:
1ST PACIFIC COAST HOMES II
FACILITY NUMBER:
415600833
ADMINISTRATOR/
DIRECTOR:
DEBORAH M. DAHLEN
FACILITY TYPE:
740
ADDRESS:
2585 ARDEE LANE
TELEPHONE:
(650) 873-8635
CITY:
SOUTH SAN FRANCISCO
STATE:
CA
ZIP CODE:
94080
CAPACITY:
6
CENSUS:
2
DATE:
04/26/2024
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME VISIT/
INSPECTION BEGAN:
01:29 PM
MET WITH:
Deborah Dahlen
TIME VISIT/
INSPECTION COMPLETED:
03:45 PM
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On 4/26/24 LPA Grace Donatoconducted an unannounced annual visit to the facility. LPA met with the administrator Deborah Dahlen and explained the purpose of the visit.
LPA toured the facility inside and outside. While touring the facility it was observed that the temperature was af 78 deg F. Hot water was also tested and temperature was 108 deg F. Each resident rooms were checked. The residents have adequate amount of linens and incontinence care items. All personal belongings are intact. All residents are comfortable and taken care of. Carbon monoxide monitor is working properly. All fire extinguishers have been checked. Bathrooms were observed to be in good repair equipped with non-skid mats and grab bars. There is also adequate amount of food. 2 days for perishables and & 7 days non-perishable. Sharps and toxic materials are locked. Emergency drills are done quarterly.
Medication review was done and all medications are accounted for and centrally stored medication records are updated.
Three staff records and two resident records was reviewed. All staff has criminal record clearance and are associated with the facility. Resident records are checked and all are complete and updated.
Licensee to submit Liability Insurance to LPA.
No deficiency cited today. Report is reviewed and copy is provided.
SUPERVISORS NAME
:
April Cowan
LICENSING EVALUATOR NAME
:
Grace Donato
LICENSING EVALUATOR SIGNATURE
:
DATE:
04/26/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
04/26/2024
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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