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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600066
Report Date: 12/12/2024
Date Signed: 12/12/2024 12:50:33 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 12/12/2024 12:50 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:JUDY'S HOME FOR THE ELDERLYFACILITY NUMBER:
415600066
ADMINISTRATOR/
DIRECTOR:		ROIAS, MICHELLEFACILITY TYPE:
740
ADDRESS:3425 PACIFIC BOULEVARDTELEPHONE:
(650) 525-9410
CITY:SAN MATEOSTATE: CAZIP CODE:
94403
CAPACITY: 6CENSUS: 6DATE:
12/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Caregiver - Concepcion LaxamanaTIME VISIT/
INSPECTION COMPLETED:
12:45 PM
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On 12/12/2024, Licensing program Analyst (LPA) Jaime Vado conducted an unannounced required - 1 year inspection. LPA met with Administrator Concepcion Laxamana and explained the purpose of today’s visit. Currently there are 6 residents and 3 staff present.

This is a single level facility with 6 bedrooms for residents. The facility is licensed for age 60 and over. All may be non-ambulatory. With a hospice waiver for 4 residents. At this time there are 4 residents under hospice care. LPA Vado toured the facility both inside and outside. All outdoor and indoor passageway are free and clear of obstructions for emergency exit routes in case of fire or emergency. Facility's ambient temperature is comfortable for residents and LPA. No pools or bodies of water were observed during today's visit on the premises. LPA observed fresh food supplies and emergency one week of nonperishable and two (2) days of perishable foods as in place. Knives are locked in the medication room which is located in the hallway that leads to the backyard. Toxic chemicals are stored in a storage area to the rear of the facility. An outdoor storae are is observed to house additional cleaning supplies and chemicals including additional PPE and incontinence supplies are observed to be in place in the medication room and the outdoor storage area. Medications are locked in the medication room along with resident and staff files. Each client room observed contained the required furniture as outlined in de dlations . Facility has functioning smoke detectors within the facility as well as carbon monoxide detectors located through out the facility. LPA observed carbon monoxide detector in the central hallway where all client rooms are located. The facility is equipped with two full bathrooms which are in good working order. Water temperature is tested at 108F. There are two fire extinguishers in the facility. Both are located at the end of each hall central to the resident rooms. Both are charged and ready for use with tagged inspection date of 07/24/2024. Fire panel is observed in the medication room with an inspection date of 06/05/2024.

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SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Jaime Vado
LICENSING EVALUATOR SIGNATURE: DATE: 12/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/12/2024
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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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: JUDY'S HOME FOR THE ELDERLY
FACILITY NUMBER: 415600066
VISIT DATE: 12/12/2024
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LPA observed all resident rooms as clean, free of odors, and contained all the required furniture per regulatory recommendations. Resident bathrooms are observed as clean and in good worker order. LPA observed resident linen supplies and incidentals also store in hallway closets. Shower floors are equipped with non-skid mats or flooring. LPA inspected the medications and files of all 6 residents in care at the facility. Based on review of all resident files, and medications all items are current and logged accurately. Disaster fire drill last conducted on 12/18/2024 per log reviewed. Facility administrator certificate is observed as current expiring 12/24/2024.

The following updated forms are requested to be submitted to CCLD by 12/19/2024:

• Copy of updated administrator certificates
• Copy of facility's liability insurance
• LIC308 Designation of responsible staff person
• LIC610E Emergency Disaster Plan
• LIC500 Staff Schedule
• Copy of control of property or copy of lease

There are no citations issued during today's visit but a technical violation and technical assistance is being issued on the attached LIC9102 forms. Report is reviewed with Concepcion Laxamana and a copy is provided on this day.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Jaime Vado
LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2024
LIC809 (FAS) - (06/04)
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