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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601187
Report Date: 10/02/2024
Date Signed: 10/02/2024 09:35:41 AM

Document Has Been Signed on 10/02/2024 09:35 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:ST. PETER'S HOME INC.FACILITY NUMBER:
415601187
ADMINISTRATOR/
DIRECTOR:		RAXAKOUL, MIRRAFACILITY TYPE:
740
ADDRESS:2311 TIPPERARY AVE.TELEPHONE:
(650) 550-3923
CITY:SOUTH SAN FRANCISCOSTATE: CAZIP CODE:
94080
CAPACITY: 6CENSUS: 6DATE:
10/02/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:25 AM
MET WITH:Mirra RaxakoulTIME VISIT/
INSPECTION COMPLETED:
09:45 AM
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On 10/2/2024 LPA Grace Donato made pre-licensing visit to the facility. LPA met with Administrator Mirra Raxakoul. LPA explained the purpose of the visit.

LPA toured the facility inside and outside including all of resident rooms, kitchen area and garage. LPA observed residents leaving for day program. 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 110 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.

Centrally stored medication was locked in the medicine cabinet and inaccessible by residents.

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: Andrea Medlin
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE: DATE: 10/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/02/2024
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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