<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600135
Report Date: 05/31/2024
Date Signed: 05/31/2024 03:06:27 PM

Document Has Been Signed on 05/31/2024 03:06 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 CARLOS ELMSFACILITY NUMBER:
415600135
ADMINISTRATOR/
DIRECTOR:
EVANS, SCOTTFACILITY TYPE:
740
ADDRESS:707 ELM STREETTELEPHONE:
(650) 595-1500
CITY:SAN CARLOSSTATE: CAZIP CODE:
94070
CAPACITY: 130CENSUS: 107DATE:
05/31/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:51 AM
MET WITH:Maribel Carino & Kirstin MarcosTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 5/31/24, LPA Grace Donato made an unannounced annual visit to the facility. LPA met with Director of Health Services (DHS), Maribel Carino & Associate Director of Operations (ADO), Kirstin Marcos. LPA explained the purpose of the visit.

LPA toured the facility including a random sample of resident rooms, common areas, and kitchen area. LPA observed some residents were having exercise activities, watching TV in the living area. While touring the facility it was observed that the temperature was at 76 deg F. Hot water was also tested in the resident rooms and the temperature was 108 deg F. The residents have adequate amount of linens and incontinence care items. All personal belongings are intact. Facility has a sprinkler system. All fire extinguishers have been checked and current. Resident bedrooms and bathrooms were observed to be in good repair equipped with grab bars and non-skid floors. Resident call lights were checked and functioning. There is adequate amount of food, 2 days for perishables and & 7 days non-perishable. Emergency drill are done every month.

Six resident records and six staff records were reviewed. Resident records are updated, complete and signed. Staff records are complete, with training logs that have met the basic 20hr requirement. Facility has 4 certified administrators on site with complete certification and training requirements. Medication review was done, and all medications are accounted for, and centrally stored medication records are updated.

LPA received the following documents LIC 308, LIC610E, LIC 309, Copy of Deed.

No deficiencies are cited at this time. Report is reviewed and copy is provided.
SUPERVISORS NAME: Andrea Medlin
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE: DATE: 05/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/31/2024
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 1