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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600066
Report Date: 01/12/2026
Date Signed: 01/12/2026 02:48:29 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 01/12/2026 02:48 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: 5DATE:
01/12/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Caregiver - Concepcion LaxamanaTIME VISIT/
INSPECTION COMPLETED:
02:15 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 5 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 3 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 storage 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 regulations. Facility has functioning smoke detectors within the facility as well as carbon monoxide detectors located through out the facility.

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NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: Jaime Vado
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 01/12/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/12/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
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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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: 01/12/2026
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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 107F in 3 resident rooms full baths. 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 08/07/2025. Fire panel is observed in the medication room with an inspection date of 07/31/2025. Fire pull is observed to be located near the front door. 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 12/09/2025 per log reviewed. Facility administrator certificate is current.

The following updated forms are requested to be submitted to CCLD by 01/19/2026:

• Copy of updated administrator certificates
• LIC308 Designation of responsible staff person
• LIC500 Staff Schedule

There are no citations issued during today's inspection visit.

Report is reviewed with Concepcion Laxamana and a copy is provided.
NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: Jaime Vado
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/12/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2026
LIC809 (FAS) - (06/04)
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