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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600080
Report Date: 04/24/2025
Date Signed: 04/24/2025 02:39:20 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 04/24/2025 02:39 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/
DIRECTOR:		VIDUCICH, ELIZABETHFACILITY TYPE:
740
ADDRESS:1661 MCKINLEY STREETTELEPHONE:
(650) 570-6475
CITY:SAN MATEOSTATE: CAZIP CODE:
94403
CAPACITY: 6CENSUS: 5DATE:
04/24/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Administrator - Elizabeth ViducichTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
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On 04/24/2025, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced required 1 year inspection. LPA met with caregiver Emely De La Cruz and explained the purpose of today's visit. Later during the visit the administrator Elizabeth Viducich arrived and met with LPA. Currently there are 5 residents in place and 3 staff, one of which is the administrator.

The facility is licensed for age range 60 and over. All may be bedridden. The facility has a hospice waiver in place for 4 residents. 2 residents are currently on hospice. This is a single level facility. The facility ambient temperature is comfortable. There are 6 resident rooms. All rooms contain a half bathroom. Water temperature is tested in the common hallway full bathroom measuring as 114F. Cleaning supplies are observed to be locked in a hallway closet. Facility knives are observed to be locked in the hallway closet as well. Kitchen food supplies are observed to be in place with 2 day fresh food supply and canned goods fulfilling the 7 day emergency food supply. Canned goods are stored in a large hallway closet. The garage has three additional refrigerators for resident food. Laundry area is observed in the garage as well and is fully operational. Emergency water is stored in the garage as well. A tour of the outside of the facility is conducted. Emergency routes are free and clear of any obstructions. Smoke detectors and carbon monoxide detectors are located through out the facility. The facility is also equipped with 1 fire alarm pull in the front of the facility next to the front door. LPA observed 2 fire extinguishers in the facility with inspection tags dated 04/15/2025. Facility conducts emergency drill quarterly. The last drill that was conducted is logged as March 2025. Linens are in place for resident use stored in a hallway closet.

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NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: Jaime Vado
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/24/2025
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 5
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: SAN MATEO VILLA
FACILITY NUMBER: 415600080
VISIT DATE: 04/24/2025
NARRATIVE
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LPA observed all resident rooms and observed that they contain the required furniture and lighting as outlined in Title 22. Medications, first aid kit, and sharps are stored appropriately. Toilet and bathing facilities are equipped with grab bars and non-skid mats. Hygiene supplies are in place. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed as current. LPA reviewed 3 staff files and 5 resident files on this day which appear to be current based on review. Staff training records are observed to be in place. Training has not been conducted based on file reviews within the last year. Administrator certificate for Elizabeth Viducich is observed as current expiring 08/27/2026.

The following updated items are to be received by 05/01/2025:
• Copy of updated administrator certificate
• Copy of facility's liability insurance
• LIC308 Designation of responsible staff person
• LIC610E Emergency Disaster Plan
• LIC500 Staff Schedule
• Copy of control of property or copy of lease

Report is reviewed with Elizabeth Viducich. A copy of this report is provided to the facility.
NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: Jaime Vado
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2025
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 04/24/2025 02:39 PM - It Cannot Be Edited


Created By: Jaime Vado On 04/24/2025 at 12:16 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: SAN MATEO VILLA
FACILITY NUMBER: 415600080

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/24/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/01/2025
Section Cited
HSC
1569.625(b)(2)

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(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. This regulation has not been met as evidenced by:
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Proof that staff received required 8 hours of dementia training to be sent to CCLD BY DUE DATE
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Based on file review conducted, caregiving staff #1 and #3 have not had annual training within the last year. Last staff training on file is documented in 2016 and 2017. There is no evidence that direct care staff received required annual dementia training . This poses a potential health and safety risk to residents in care.
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Type B
05/01/2025
Section Cited
HSC1569.696(a)

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(a) All residential care facilities for the elderly shall provide training to direct care staff on postural supports, restricted conditions or health services, and hospice care as a component of the training requirements specified in Section 1569.625. The training shall include all of the following:
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Proof that staff received required 4 hours of training on hospice care, postural supports and restricted health conditions will be sent to CCLD BY DUE DATE.
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Based on file review conducted, caregiving staff #1 and #3 have not had annual training within the last year. Last staff training on file is documented in 2016 and 2017. There is no evidence that staff have received annual 4 hours of training on hospice care, postural supports, restricted health conditions. Staff does not have proof of postural supports and restricted health conditions training. This poses a potential health and safety risk to residents in care.
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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.
April Cowan
NAME OF LICENSING PROGRAM MANAGER:
Jaime Vado
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/24/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/24/2025 02:39 PM - It Cannot Be Edited


Created By: Jaime Vado On 04/24/2025 at 12:28 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: SAN MATEO VILLA
FACILITY NUMBER: 415600080

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/24/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/01/2025
Section Cited
CCR
87506(a)

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87506(a) Resident Records. A separate, complete, and current record shall be maintained for each resident in the facility, readily available to facility staff and to licensing agency staff and shall contained specified information. This regulation has not been met as evidenced by:
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Facility shall ensure that all residents with dementia have either a current physicians report or other assessment showing the resident has no change from last physician's report.
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Based on resident files reviewed, resident #1 does not have current physicians reports. Resident's reports are over 1 year old with no updated assessments or reports on file. This poses a potential health and safety risk for residents in care.
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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.
April Cowan
NAME OF LICENSING PROGRAM MANAGER:
Jaime Vado
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/24/2025


LIC809 (FAS) - (06/04)
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