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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600080
Report Date: 06/09/2022
Date Signed: 06/09/2022 10:44:35 AM


Document Has Been Signed on 06/09/2022 10:44 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
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:
94403
CAPACITY:6CENSUS: 6DATE:
06/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Administrator, Elizabeth ViducichTIME COMPLETED:
10:50 AM
NARRATIVE
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On June 9, 2022, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced annual infection control inspection. Upon arrival LPA observed the COVID signage postage on the front door. LPA Charitra was greeted by Caregiver, Emely De La Cruz and Administrator, Elizabeth Viducich joined shortly thereafter. LPA explained the purpose of the visit and was screened at entry point, however there was no visitor sign in log. Caregiver was unable to provide screening log documentation for staff, residents and visitors.

LPA toured facility and grounds. No accessible bodies of water or fire safety hazards observed. This is a single story with 7 bedrooms (6 private rooms for residents with a half bath in each room and 1 staff room), and 1 full bathroom. LPA observed the bathrooms to be equipped with liquid hand soap and hand washing signs. LPA advised Adminsitrator to ensure all bathrooms have the following; paper-towels and a covered trash bin. LPA Charitra indicated that hand-towels and bath-towels should not be present in the shared bathrooms. LPA toured the kitchen and advised Administrator to switch out hand-towels for paper-towels and disinfectant wipes.

LPA observed 2 day perishable and 7 day non-perishable. LPA observed the 30-day PPE supply. Medications and toxins are stored appropriately and inaccessible to residents, however LPA observed sharps drawer to be unlocked and accessible to residents. A comfortable temperature is maintained, lighting is sufficient for comfort. First aid kit was observed to be completed. Extra linen was observed to be present.

Deficiency of the Residential Care Elderly California Code of Regulations, Title 22, Division 6 is observed and cited on a LIC 809D. Failure to correct the deficiencies may result in civil penalties.

This report is reviewed and discussed with Administrator; a copy is provided with appeals rights.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 06/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/09/2022
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


Document Has Been Signed on 06/09/2022 10:44 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 VILLA
FACILITY NUMBER: 415600080

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/09/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(1)
87705 Care of Persons with Dementia: (f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).


This requirement is not met as evidenced by:

Deficient Practice Statement
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Based on observations, the facility failed to lock the knives or store them appropratiely so it is inaccesible to residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/10/2022
Plan of Correction
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Deficiency was fixed in LPA's prescence. Administrator moved kitchen knives and moved it into the locked cabinet with the chemicals. Deficiency corrected and cleared.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 06/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/09/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 06/09/2022 10:44 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 VILLA
FACILITY NUMBER: 415600080

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/09/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87468.1(a)(2)
(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.

This requirement is not met as evidenced by
Deficient Practice Statement
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Based on observation, the facility failed to provide documentation for the daily residents and staff members screening log; the facility failed to provide documentation for the visitor's screening log.
POC Due Date: 06/16/2022
Plan of Correction
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The Administrator and/or designee will review the Department's Provider Information Notices (PINs) regarding the daily COVID-19 screening process for visitors, residents and staff members and start documenting the results of the screening outcomes on a log to indicate that it was done.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 06/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/09/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3