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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601144
Report Date: 04/09/2024
Date Signed: 04/09/2024 10:46:31 AM

Document Has Been Signed on 04/09/2024 10:46 AM - 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:STEPHANIE LILY HOME INCFACILITY NUMBER:
415601144
ADMINISTRATOR/
DIRECTOR:
VERIDIANO, STEPHANIE LILIAFACILITY TYPE:
740
ADDRESS:776 DEL MONTE AVENUETELEPHONE:
(650) 757-7115
CITY:SOUTH SAN FRANCISCOSTATE: CAZIP CODE:
94080
CAPACITY: 6CENSUS: 6DATE:
04/09/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:08 AM
MET WITH:Rommel Dionson & Stephanie VeridianoTIME VISIT/
INSPECTION COMPLETED:
11:15 AM
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On 4/9/2024 LPA Grace Donato made pre-licensing visit to the facility. LPA met with Administrator Stephanie Veridiano & Co-Administrator Rommel Dionson. LPA explained the purpose of the visit.

LPA toured the facility inside and outside including all of resident rooms and kitchen area. LPA observed one resident resting in their bedroom and two residents in the living room. 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 106 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. Food supply was observed with an adequate two day perishable and seven day non-perishable food supply. Carbon monoxide detector and fire extinguishers were present throughout the facility. Facility has an updated log for emergency drill will is done every month.

Two resident records and two staff records were reviewed. Staff have criminal record and fingerprint clearances on file. Staff have current First Aid/CPR certifications on file. Resident records were reviewed and were observed to be complete with documents such as Admission Agreements, Medical Assessments, and Needs and Service Plans.

Centrally stored medication was locked in the medicine cabinet and inaccessible by residents. All medication logs are complete and updated.

Component III is conducted on this day.

Facility is in compliance with Title 22 regulations. No citations are issued. Report is reviewed copy is provided.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE: DATE: 04/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/09/2024
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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