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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601122
Report Date: 11/29/2021
Date Signed: 11/29/2021 12:53:32 PM

Document Has Been Signed on 11/29/2021 12:53 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
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:ARBOR HOUSEFACILITY NUMBER:
415601122
ADMINISTRATOR:ALEJANDRO, VICTORIAFACILITY TYPE:
740
ADDRESS:330 ARBOR DRIVETELEPHONE:
(510) 825-2287
CITY:SOUTH SAN FRANCISCOSTATE: CAZIP CODE:
94080
CAPACITY: 4CENSUS: 3DATE:
11/29/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Administrator, Roy JohnsonTIME COMPLETED:
01:00 PM
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On 11/29/21 at 10AM, Licensing Program Analyst (LPA), Murial Han met with the Administrator, Roy Johnson to conduct an unannounced Pre-Licensing inspection for change of ownership. LPA Han was properly screened by the Administrator at the entry and LPA observed COVID-19 signs posted by the front entry. The new Administrator, Victoria Alejandro also arrived at the facility for the inspection.

LPA observed the indoor and the outdoor passageways are free of obstruction.

The Administrator provided a tour of the facility and all the clients were at the Day Program during the inspection.

This is a one story facility with 4 private bedrooms. Three rooms are occupied. The client's rooms, the living room, the kitchen, the shower room, the bathrooms and the dining room are well maintained and appeared to be cleaned. The overall facility temperature was measured at 72 degrees Fahrenheit (F). the hot water temperature was measured in the half bathroom, shower room and the kitchen were at 115- 118 degrees F.

The laundry room was cleaned and chemicals were locked. The medication storage was locked and inaccessible to the residents. The Carbon Monoxide detectors were present and properly operated. The first aide kit was inspected and equipped. Food supplies were observed to be adequate. The refrigerator temperature was measured at 34 degrees F and the freezer was measured at -1 degree F.

The fire and smoke detectors are observed to be operated properly, the fire extinguishes observed to be adequate, and the Administrator reported that there is no firearms and/or ammunition at the facility.
SUPERVISORS NAME: Julio Montes
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE: DATE: 11/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/29/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: ARBOR HOUSE
FACILITY NUMBER: 415601122
VISIT DATE: 11/29/2021
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The Activities Calendar, the Resident Rights, the Ombudsman, the House Rules, the Licensing Complaint Poster and the Resident Council Rights are posted. In addition, there are COVID-19 signs to be observed through-out the facility and in the bathrooms.

PPE supplies are adequate, facility continues to conducted COVID-19 screening for all clients twice a day and staff once a day upon their arrival. In addition, staff members are randomly tested for COVID-19 every other week.

There were no objects obstructing the emergency shut-offs: water, electricity (all locations are labeled) and gas shut-off stations.

There are many digital communication devices observed around the facility to improve the communication between clients and staff.

Facility sketch accurately reflects the floor plan.

Comp III orientation was given to the new Administrator, Victoria Alejandro on 11/29/2021.

Pre-Licensing is now complete. Immediate Licensure is recommended pending final approval from the Central Applications Bureau.

Exit interview conducted with the Administrator, Roy Johnson and the new Administrator, Victoria Alejandro. A copy of the report was provided.
SUPERVISORS NAME: Julio Montes
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:

DATE: 11/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2021
LIC809 (FAS) - (06/04)
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