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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600534
Report Date: 07/23/2021
Date Signed: 07/23/2021 04:15:59 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:M. S. CARE HOMEFACILITY NUMBER:
415600534
ADMINISTRATOR:STEFANAC, SUZIFACILITY TYPE:
740
ADDRESS:435 PORTOLA DRIVETELEPHONE:
(650) 345-6456
CITY:SAN MATEOSTATE: CAZIP CODE:
94403
CAPACITY:6CENSUS: 4DATE:
07/23/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:34 AM
MET WITH:Kesaeya VodonaivaluTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Gladys Kuizon conducted an annual inspection today and met with Administrator Kesaeya Vodonaivalu.

At 10:34 AM, LPA entered the facility through the facility's central entry point and was screened by staff. At 10:45 AM, a tour of the facility was conducted. COVID-19 postings were observed. Staff were observed wearing face coverings. 4 residents and 2 staff caregivers were present during inspection. Residents' bedrooms and bathrooms were inspected. The facility's main hallway flooring is currently being updated.

The facility has at least 30 days' supply of personal protective equipment (PPE) including isolation gowns, gloves, and face masks. Hand sanitizers, soap, and paper supplies were observed available. At least 2 days' supply of perishable foods and at least 1 week's supply of non-perishable foods are available in the premises.

According to Administrator, the facility has achieved 100% vaccination rate against COVID-19 for both residents and staff. The facility is currently accepting visitors inside the facility.

The facility's mitigation plan was received by Community Care Licensing. LPA recommends the following:
1. Place paper towels in dispensers or spools to minimize contamination.
2. Update facility's resident roster and ensure emergency contact information is current for all residents.
3. Ensure complete list of COVID-19 symptoms are being used during entrance screening procedure.

No deficiencies were cited. Exit interview conducted with Administrator and a copy of this report was provided during visit.
SUPERVISOR'S NAME: George NwaforTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Gladys KuizonTELEPHONE: (408) 834-2558
LICENSING EVALUATOR SIGNATURE:

DATE: 07/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2021
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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