415600080-12-2-2023-14-AS-APAA-CY62DA-20231202161758

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 415600080
Report Date: 12/02/2023
Date Signed: 12/02/2023 04:18:11 PM

Document Has Been Signed on 12/02/2023 04:18 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 VILLA		FACILITY NUMBER:	415600080
ADMINISTRATOR:	VIDUCICH, ELIZABETH		FACILITY TYPE:	740
ADDRESS:	1661 MCKINLEY STREET		TELEPHONE:	(650) 570-6475
CITY:	SAN MATEO	STATE: CA	ZIP CODE:	94403
CAPACITY:	6	CENSUS: 5	DATE:	12/02/2023
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Elizabeth Viducich		TIME COMPLETED:	03:00 PM

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On 12/2/2023, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to conduct an annual visit. LPA met with staff member, Emiley De La Cruz and explained the purpose of the visit. LPA asked that SM De La Cruz called the Facility Designated Administrator to inform them the CCL was present at this time. There were two other staff members present at the time of this this visit, Nicole Dasig and Felina Mallazab.
This facility is licensed to serve and retain 6 elderly residents, all of which may be bedridden. This facility also has a dementia plan on file and hospice waiver for 4 residents.
Current census was 5. It was learned that the facility has 1 resident on hospice at this time.
LPA reviewed 5 resident files and 4 staff files. The administrator has an active administrator certificate #6019095740 and expires on 08/27/2024.
A tour of the facility was conducted. The interior of the physical plant was in good condition and sanitary. Fire extinguishers appeared to have been annually inspected by Reliable Fire Extinguisher Company on 04/13/2023.
The kitchen area was toured. LPAs observed a non-perishable and perishable foods in the cabinets and refrigerator. Additional perishable food supplies were identified in the garage.

LPA observed a locked centralized stored medication cabinet located in the kitchen. Along with the administrator, the LPA observed, reviewed, and compared resident medication and medication dispensing logs. First Aid Kit was present and contained all of the required components.

A tour of the bathrooms was conducted. Hot water temperature was measured and observed to be within the required range of 105-120 degrees. A linen closet was located in the hallway and presented a sufficient amount of linens to adequately supply and meet the needs of the residents at this time.

A tour of the bedrooms was conducted. Resident furniture was observed to be sufficient to meet their needs at this time.

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arielle Pascua	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 12/02/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2023

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: SAN MATEO VILLA	FACILITY NUMBER: 415600080
	VISIT DATE: 12/02/2023

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Laundry area was toured. Laundry detergent, bleach, and all other cleaning supplies were observed to be locked and made inaccessible to the residents at this time.

Common areas were toured. Living room, dining area and all other areas intended for resident use were observed to be furnished and maintained in compliance at this time.

A tour of the garage was conducted. Additional perishable food supplies were identified.

The exterior of the physical plant was toured. Perimeter fence was observed to be stable and gates were in good repair.

The following forms and documents were requested to be updated and submitted into CCL

-LIC 308

-LIC 400

-LIC 500

-LIC 610

A technical violation is being provided for Section 87355(e)(2) and a technical advisory is being provided for Section 87457(a) and 87465(h)(5)

As a result of this visit, no deficiencies were observed or cited during this annual visit. An exit interview was conducted and copy of the 809 and 809-C was provided to facility at the end of this visit.

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arielle Pascua	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 12/02/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2023

LIC809 (FAS) - (06/04)

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