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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600080
Report Date: 06/29/2021
Date Signed: 06/29/2021 05:33:57 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:SAN MATEO VILLAFACILITY NUMBER:
415600080
ADMINISTRATOR:VIDUCICH, ELIZABETHFACILITY TYPE:
740
ADDRESS:1661 MCKINLEY STREETTELEPHONE:
(650) 570-6475
CITY:SAN MATEOSTATE: CAZIP CODE:
94402
CAPACITY:6CENSUS: 5DATE:
06/29/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Emely De La Cruz and Elizabeth ViducichTIME COMPLETED:
11:00 AM
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On June 29, 2021 Licensing Program Analyst (LPA) Chris Hopkins conducted an unannounced annual required inspection. LPA met with caregiver Emely De La Cruz and stated the purpose of the visit. Licensee Elizabeth Viducich showed up at a later time.

LPA toured the indoor and outdoor premises of the facility. The indoor and outdoor passageways were free of obstruction. LPA observed the resident bathroom, and it is equipped with non-skid flooring and grab bars. Bathroom is sanitary and odorless. The hot water temperature was measured in residents bathroom at 107 degrees Fahrenheit. The facility is observed to be clean, odorless, and well maintained. Residents bedrooms were observed to be well organized and fully furnished with adequate lighting. Sharps and toxic materials were observed locked in the garage and inaccessible to residents. Food supply in kitchen and garage refrigerator/freezer was observed with an adequate two day perishable and seven day non-perishable food supply. Carbon monoxide, smoke detectors, and fire extinguisher were present at the facility. Centrally stored medication was locked in the kitchen cabinet and inaccessible by residents. All medication was labeled and sorted by resident name.

Staff records were reviewed. Staff have criminal record and fingerprint clearances on file. Resident records were reviewed and were observed to be complete with documents such as Admission Agreements, Medical Assessments, and Needs and Service Plans.

No deficiencies observed today. Facility is operating in compliance with Title 22 regulations. This report was discussed with Licensee, Elizabeth Viducich, and a copy of this report was provided via email.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Christopher Hopkins-ClarkeTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 06/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2021
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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