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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600251
Report Date: 04/29/2024
Date Signed: 05/01/2024 09:40:06 AM


Document Has Been Signed on 05/01/2024 09:40 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
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066



FACILITY NAME:ROIAS HOME FOR THE ELDERLYFACILITY NUMBER:
415600251
ADMINISTRATOR:ROIAS, JUDYFACILITY TYPE:
740
ADDRESS:311 28TH AVENUETELEPHONE:
(650) 627-8824
CITY:SAN MATEOSTATE: CAZIP CODE:
94403
CAPACITY:6CENSUS: 6DATE:
04/29/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Mercy Moreiraand Judy RoiasTIME COMPLETED:
07:15 PM
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LPA Audrey Jeung toured facility and grounds, consisting of 6 client bedrooms and 2 staff bedrooms--all with half bathrooms--full bath/shower room, living/dining area, kitchen, recreation room. There are two beds in each staff room. Washer and dryer are located in attached garage, which also accesses stairs to upper level storage rooms. An accessory dwelling unit (ADU) is being built in backyard. No accessible bodies of water or fire safety hazards observed. PPE supply is adequate. Medications, toxins and sharps are stored appropriately and inaccessible to clients, a comfortable temperature is maintained, and lighting is sufficient for comfort and safety. Toilet and bathing facilities are equipped with grab bars and nonskid flooring material. Liquid soap is available at all sinks. First-aid kit is inspected and complete. A Disaster and Mass Casualty Plan is posted. There are 6 residents present, and 2 staff. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed, as well as staff records. Judy Roias, Michelle Roias, and Mercy Moreira are certified RCFE administrators (x 5/25, 5/25, 12/24) that oversee facility operations. Client records are reviewed, including hospice care plans for 3 residents.

The following updated forms/information are requested to be submitted to CCLD BY 5/13/24:

• LIC 308 Designation of Administrative Responsibility
• LIC 500 Personnel Report
• LIC 610E Emergency Disaster Plan (page 9 signed and dated)
• Building Permit for ADU
- Revised sketch of facility grounds (including ADU)


Deficiency of the RCFE California Code of Regulations, Title 22, Division 6, Chapter 8 is observed and cited on a following page.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:
DATE: 04/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/29/2024
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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Document Has Been Signed on 05/01/2024 09:40 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
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066


FACILITY NAME: ROIAS HOME FOR THE ELDERLY
FACILITY NUMBER: 415600251

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(c)(5)
CARE OF PERSONS WITH DEMENTIA
Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on client records review, the licensee did not comply with the section cited above, as two out of 5 clients with dementia do not have current MD reports and/or appraisals. This poses a potential health, safety or personal rights risk to persons in care.
Clients #5 and #6 both have MD reports dated 1/22 and appraisals dated 2/22 and 1/20 respectively.
POC Due Date: 05/13/2024
Plan of Correction
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MD reports and appraisals for clients #5 and #6 will be updated and copies sent to CCLD BY DUE DATE.
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: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:
DATE: 04/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/29/2024
LIC809 (FAS) - (06/04)
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