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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600026
Report Date: 02/26/2025
Date Signed: 02/26/2025 01:41:27 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 02/26/2025 01:41 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:ROBERTA HOMEFACILITY NUMBER:
415600026
ADMINISTRATOR/
DIRECTOR:		PALERACIO, ALICIAFACILITY TYPE:
735
ADDRESS:1655 ROBERTA DRIVETELEPHONE:
(650) 341-4996
CITY:SAN MATEOSTATE: CAZIP CODE:
94403
CAPACITY: 6CENSUS: 6DATE:
02/26/2025
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Home Manger - Marievic DumaloTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
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On 02/26/2025, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced annual inspection visit. LPA met with staff person Mariejane Baris initially and around 1130am the house manager Marievic Dumlao. LPA explained the purpose of today's visit. During today's visit there is one client present and two staff.

LPA was allowed entry into the facility. This is a single story facility. The facility is licensed for ages 18 though 59. All may be non-ambulatory. Facility is cleared for to hospice clients. There are no clients on hospice during today's inspection. The physical plant was toured inside and outside of the facility to ensure the safety of the clients. LPA observed the facility kitchen which is clean and observed appliances are in good repair. Knives are stored and locked in the kitchen in a drawer. Medications are observed to be locked in a cabinet as well in the kitchen. Perishable and non-perishable food items are observed as in place. There is an additional freezer in the backyard under a sheltered awning for client frozen supplies. There are additional emergency food supplies in the garage in a cabinet for client and facility use. Cleaning supplies are observed to be locked. First aid kit is observed as complete with required items stored with the medications. LPA observed that there are multiple fire extinguishers in place last inspected 03/05/2024, smoke detectors, carbon monoxide detectors are observed in place through out the facility, facility smoke detectors are hard wired, and central heating system including AC units and fans in client bedrooms. Fire panel is observed in the garage as last inspected on 02/12/2025. Facility is also equipped with fire alarm pull station near the front door. PPE and additional food supplies are observed as in place in storage shed and in the facility. Laundry area is also observed as fully operational in the garage. Emergency exit routes are observed inside and outside to be free and clear of obstructions. Water temperature was measured at 106F in a common bathroom in the rear of the facility. Client room in the front of the facility contains a full bath but the shower is not used according to staff. Water temp is tested at 108F in this bathroom. Another bathroom is also in the front of the facility for client use with water temperature of 105F.

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SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Jaime Vado
LICENSING EVALUATOR SIGNATURE: DATE: 02/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/26/2025
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: ROBERTA HOME
FACILITY NUMBER: 415600026
VISIT DATE: 02/26/2025
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LPA observed client rooms at random and all appeared clean, free of odors, and contained all the required furniture per regulatory recommendations. Client linen supplies are observed as in place. There is one staff room assigned to the facility. During today's visit LPA reviewed 5 client and 4 staff files of which all are current. Facility does handle client P&I. This is audited and is current based on count and P&I log reviewed and money count conducted by Marievic. Client medications are reviewed and are current per medications administration record. Last disaster drill conducted on 01/19/2025. Administrator/Licensee Alicia Paleracio admin certificate is observed as current expiring 03/17/2025.

The following updated forms are requested to be submitted to CCLD by 03/05/2025:

• Copy of updated Administrator Certificate
• Copy of facility's liability insurance
• Copy of current surety bond
• LIC308 Designation of responsible staff person
• LIC400 Affidavit Regarding Client/Resident Cash Resources
• LIC610D Emergency Disaster Plan
• LIC500 Staff Schedule
• Copy of control of property or current lease

No citations are issued on this day. Report is reviewed with house manager Marievic Dumalo.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Jaime Vado
LICENSING EVALUATOR SIGNATURE:

DATE: 02/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2025
LIC809 (FAS) - (06/04)
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