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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600066
Report Date: 02/12/2024
Date Signed: 02/15/2024 08:06:44 AM


Document Has Been Signed on 02/15/2024 08:06 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:JUDY'S HOME FOR THE ELDERLYFACILITY NUMBER:
415600066
ADMINISTRATOR:ROIAS, MICHELLEFACILITY TYPE:
740
ADDRESS:3425 PACIFIC BOULEVARDTELEPHONE:
(650) 525-9410
CITY:SAN MATEOSTATE: CAZIP CODE:
94403
CAPACITY:6CENSUS: 6DATE:
02/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:51 AM
MET WITH:Concepcion LaxamanaTIME COMPLETED:
11:30 AM
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On 02/12/24 LPA Grace Donato made an unannounced annual visit to the facility. LPA met with Caregiver Concepcion Laxamana. LPA explained the purpose of the visit.

LPA toured the facility inside and outside including all of resident rooms, common areas & kitchen. The indoor and outdoor passageways were free of obstruction. 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 71 deg F. Hot water was also tested in the bathrooms and the temperature was 110 deg F. Carbon monoxide and smoke detector are present in the facility. All fire extinguishers have been checked and current. Client bathrooms were observed to be in good repair equipped with grab bars and non-skid mats. 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 every three months.

Five resident records and three 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. Medication review was done, and all medications are accounted for, and centrally stored medication records are updated.

LPA requested the following documents: Certificate of Liability Insurance and LIC 500.

No deficiencies are cited at this time. Report is reviewed and a copy is provided.
SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8865
LICENSING EVALUATOR NAME: Grace DonatoTELEPHONE: (714) 293-8294
LICENSING EVALUATOR SIGNATURE:
DATE: 02/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/12/2024
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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