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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601109
Report Date: 01/14/2025
Date Signed: 01/14/2025 05:21:51 PM

Document Has Been Signed on 01/14/2025 05:21 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:KASA JOMIFACILITY NUMBER:
415601109
ADMINISTRATOR/
DIRECTOR:		CAROLYN DIZONFACILITY TYPE:
740
ADDRESS:264 SOUTHCLIFF AVENUETELEPHONE:
(650) 636-4025
CITY:SOUTH SAN FRANCISCOSTATE: CAZIP CODE:
94080
CAPACITY: 4CENSUS: 4DATE:
01/14/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:09 PM
MET WITH:Carolyn DizonTIME VISIT/
INSPECTION COMPLETED:
05:30 PM
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On 1/14/2025, LPA Grace Donato made an unannounced annual visit to the facility. LPA met with Administrator Carolyn Dizon. LPA explained the purpose of the visit.

LPA toured the facility inside and outside including all of resident rooms and kitchen area. Facility is a single story facility with four resident bedrooms and one staff room. Residents are currently napping in the bedrooms. While touring the facility it was observed that the room temperature was at 69 deg F. Hot water was also tested in the bathrooms and the temperature was 108 deg F. The facility is observed to be clean, odorless, and well maintained. Residents bedrooms were observed to be well organized and fully furnished with adequate lighting. Sharps and toxic materials were observed locked and inaccessible to residents. Food supply was observed with an adequate two day perishable and seven day non-perishable food supply. Carbon monoxide/smoke detectors, and fire extinguisher were present throughout the facility. Facility has an updated log for emergency drill will is done every month.

Four resident records and four staff records were reviewed. Centrally stored medication are complete and updated.

LPA recieved an updated LIC500 and LIC308.

No deficiencies cited today. Report is reviewed and copy is provided.
SUPERVISORS NAME: Andrea Medlin
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE: DATE: 01/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/14/2025
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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