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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 410508446
Report Date: 10/07/2025
Date Signed: 10/07/2025 06:11:58 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 10/07/2025 06:11 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:VANESSA CARE HOME IIFACILITY NUMBER:
410508446
ADMINISTRATOR/
DIRECTOR:		GALATI, IDAFACILITY TYPE:
740
ADDRESS:1640 ELEANOR DRIVETELEPHONE:
(650) 315-2114
CITY:SAN MATEOSTATE: CAZIP CODE:
94402
CAPACITY: 6CENSUS: 5DATE:
10/07/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:15 PM
MET WITH:Nolita Arcenio and Ida GalatiTIME VISIT/
INSPECTION COMPLETED:
06:15 PM
NARRATIVE
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LPA Jeung toured facility and grounds, which includes a fenced backyard and 2-car garage. There are 6 client bedrooms and 2 staff rooms--one has one bed and the other has 2 beds--common bathroom, large living/dining area, and kitchen with eat-in dining table. All bedrooms have private full bathrooms and direct exits to outside. There are no accessible bodies of water or fire safety hazards observed. Sharps are stored appropriately and inaccessible to clients, and a comfortable temperature is maintained. Hot water temperature is tested within range of 105 and 120 degrees. Carbon monoxide detector is tested and operable. Food supply and first-aid kit are inspected. Client files are reviewed. A Disaster and Mass Casualty Plan is posted. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed, as well as staff records. There are 3 administrators associated to this facility: Licensee Ida Galati (x 7/26), Crystal Wright (x 10/26), Tina Galati (x 2/26).

The following information/forms are requested to be sent to CCLD BY 10/2125:

- LIC 308 Designation of Facility Responsibility
- LIC 500 Personnel Report
- Proof of current liability insurance

Deficiencies of the RCFE California Code of Regulations, Title 22, Division 6, Chapter 8 are observed.
See also Technical Advisory Notes--2 pages.
NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: Audrey Jeung
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/07/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 10/07/2025 06:11 PM - It Cannot Be Edited


Created By: Audrey Jeung On 10/07/2025 at 05:08 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: VANESSA CARE HOME II
FACILITY NUMBER: 410508446

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/07/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/08/2025
Section Cited
CCR
87468.1(a)(6)

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PERSONAL RIGHTS
Residents have the personal right..to leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night. This requirement is not met, as glass sliding glass door in room #1 is secured with a screw & wood
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Wood stick and screw were removed from sliding door in room #1 and padlock was removed from side gate.
Licensee to submit plan of correction describing how client will be monitored by staff without securing exit door shut.
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stick so client cannot access the door to exit.
Side yard gate on south side is padlocked.
Licensee failed to ensure that exits are accessible to clients, which poses an immediate health, safety or personal rights risk to clients in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
April Cowan
NAME OF LICENSING PROGRAM MANAGER:
Audrey Jeung
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/07/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/07/2025 06:11 PM - It Cannot Be Edited


Created By: Audrey Jeung On 10/07/2025 at 05:18 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: VANESSA CARE HOME II
FACILITY NUMBER: 410508446

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/07/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/21/2025
Section Cited
CCR
87411(f)

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PERSONNEL REQUIREMENTS--GENL
All personnel...shall be in good health, & physically & mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than 6 months prior
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TB test results for staff #3 and #4 and health screening for Staff #4 to be sent to CCLD BY DUE DATE
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to or 7 days after employment or licensure. A report shall be made of each screening, signed by the examining physician. This requirement is not met, as there is no TB test result for Staff #3 & #4 & no health screening for staff #4.
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Type B
10/21/2025
Section Cited
HSC1569.696

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HEALTH & SAFETY CODE
All RCFEs shall provide training to direct care staff on postural supports, restricted conditions or health services, & hospice care...training shall include all of the following: 4 hours of training on the care, supervision, and special needs of those residents, prior to providing direct care to
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Staff shall received required annual training on restricted health conditions, and proof whall be sent to CCLD BY DUE DATE.
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residents... This requirement is not met, as there is no evidence that staff received training on restricted health conditions, which poses a potential health, safety or personal rights risk to clients i care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
April Cowan
NAME OF LICENSING PROGRAM MANAGER:
Audrey Jeung
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/07/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/07/2025 06:11 PM - It Cannot Be Edited


Created By: Audrey Jeung On 10/07/2025 at 05:37 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: VANESSA CARE HOME II
FACILITY NUMBER: 410508446

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/07/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/21/2025
Section Cited
CCR
87463(h)

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REAPPRAISALS
The licensee shall request that all residents receive an annual routine visit with a licensed medical professional once every 12 months, either in person or by video appointment. Documentation of the annual routine visit, such as a visit summary, shall be added to the resident's record.
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MD reports for C2 and C4 will be signed and copies to be sent to CCLD BY DUE DATE
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record. This requirement is ot met, as MD reports for clients #2 and #4 are dated more than 12 months ago. Licensee failed to ensre that annual routine medical evaluations are documented, which poses a potential health, safety or personal rights risk to clients in care.
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Type B
10/21/2025
Section Cited
CCR87468(a)

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REAPPRAISALS
The pre-admission appraisal...shall be updated in writing as frequently as necessary or once every 12 months, whichever occurs first.... and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission
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Updated, signed appraisals for 3 clients to be sent to CCLD BY DUE DATE
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appraisal shall be referred to as the reappraisal. This requirement is not met, as appraisals for clients #2, #3, #4 are dated more than 12 months ago. Licensee failed to ensure that appraisals are updated annually.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
April Cowan
NAME OF LICENSING PROGRAM MANAGER:
Audrey Jeung
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/07/2025


LIC809 (FAS) - (06/04)
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