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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600080
Report Date: 05/07/2024
Date Signed: 05/07/2024 01:50:35 PM


Document Has Been Signed on 05/07/2024 01:50 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: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:
05/07/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:13 AM
MET WITH:Emely De La CruzTIME COMPLETED:
01:00 PM
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On 5/7/24, Licensing Program Analyst (LPA) Grace Donato conducted an unannounced annual required inspection. LPA met with Lead Staff, Emely De La Cruz and explained the purpose of the visit.

LPA toured the indoor and outdoor premises of the facility. The indoor and outdoor passageways were free of obstruction. LPA observed the resident shower room, and it is equipped with non-skid mats and grab bars. Bathroom is sanitary and odorless. The hot water temperature was measured in residents bathroom at 115 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 locked in kitchen inaccessible to residents. Toxic materials were observed locked in the garage and inaccessible to residents. Food supply in kitchen and garage 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 medication cabinet. All medication was labeled and sorted by resident name.

Six 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.

LPA requested the facility to submit the following: Liability Insurance & LIC500.

No deficiencies cited today. Report is reviewed and copy is provided.
SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8865
LICENSING EVALUATOR NAME: Grace DonatoTELEPHONE: (714) 293-8294
LICENSING EVALUATOR SIGNATURE:
DATE: 05/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/07/2024
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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