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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601165
Report Date: 01/09/2025
Date Signed: 01/09/2025 06:02:16 PM

Document Has Been Signed on 01/09/2025 06:02 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:GENERATIONS CARE HOMEFACILITY NUMBER:
415601165
ADMINISTRATOR/
DIRECTOR:
MEHTA, IRENEFACILITY TYPE:
740
ADDRESS:859 CAMARITAS CIRTELEPHONE:
(650) 438-6710
CITY:SOUTH SAN FRANCISCOSTATE: CAZIP CODE:
94080
CAPACITY: 6CENSUS: 4DATE:
01/09/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:59 PM
MET WITH:Irene MehtaTIME VISIT/
INSPECTION COMPLETED:
06:15 PM
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On 1/09/25 LPA Grace Donato made an unannounced annual visit to the facility. LPA met with Administrator Irene Mehta. LPA explained the purpose of the visit.

Facility is a 4 bedroom house with 2 shared rooms. LPA toured the facility inside and outside including all of resident rooms, common areas & kitchen. The indoor and outdoor passageways were free of obstruction. Residents are currently resting in the bedrooms and living room. The residents have adequate amount of linens and all personal belongings are intact. While touring the facility it was observed that the room temperature was at 70 deg F. Hot water was also tested in the bathrooms and the temperature was 108 deg F. Carbon monoxide monitor is working properly. All fire extinguishers have been checked and current. Client bathrooms were observed to be in good repair equipped with grab bars and non-skid floors. LPA checked the food supply and there is adequate amount of food, 2 days for perishables and & 7 days non-perishable. Emergency drills are done quarterly.

Four resident records and four staff records were reviewed. Everything is complete and updated. Medication review was done, and all medications are accounted for, and centrally stored medication records are updated. Three client records and three staff records were reviewed. Resident records are updated, complete and signed.

LPA requested the Liability Insurance and LIC500 to be emailed.

No deficiencies are cited at this time. Report is reviewed and a copy is provided.
SUPERVISORS NAME: Andrea Medlin
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE: DATE: 01/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/09/2025
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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