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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600534
Report Date: 07/03/2024
Date Signed: 07/03/2024 12:37:46 PM


Document Has Been Signed on 07/03/2024 12:37 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: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: 5DATE:
07/03/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Caregiver - Talica MatainisigaTIME COMPLETED:
12:45 PM
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On 07/03/2024, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced annual inspection. LPA met with administrator Noralee Reyes and explained the purpose of today's visit. There is 2 staff present and 5 residents present.

LPA was allowed entry into the facility. This is a single level facility. Annual fees are current. The physical plant was toured inside and outside to ensure the safety of the residents. LPA observed the facility kitchen which is clean and observed appliances are in good repair. Knives are stored and locked in the kitchen in a drawer. Medications are also locked in an upper cabinet. Perishable and non-perishable food items are observed as in place. There are additional refrigerators and freezers in the garage areas which also carry additional food supplies. First aid kit is observed as complete with required items. LPA observed fire extinguishers in place inspected 10/04/2023, smoke detector/carbon monoxide detectors are observed in place through out the facility, and central heating/cooling system. Facility also has a hardwired fire alarm system and pull stations at the front and rear of the facility. PPE and additional food supplies are observed as in place. Laundry area is also observed as fully operational located beneath the facility. Emergency exit routes are observed inside and outside to be free and clear of obstructions. Water temperature was measured at 107F. Shower floor uses non-skid mat when shower is in use. LPA observed rooms at random and all appeared clean, free of odors, and contained all the required furniture per regulatory recommendations. Resident linen supplies are observed as in place.

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SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8865
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:
DATE: 07/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/03/2024
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 3


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: M. S. CARE HOME
FACILITY NUMBER: 415600534
VISIT DATE: 07/03/2024
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LPA reviewed 2 client files and also reviewed 3 staff files on this day. Per resident files reviewed they are current. Per staff files reviewed all files were current with training and CPR/First Aid for the staff persons inspected. The file for the administrator is not current with outdated items and needs to be updated with current items such as administrator certificate and first aid card. LPA is aware that the licensee has those items currently but the file this facility has not been updated. P&I is not handled by the facility. Client medications are inspected and are current.

S2's file is present but is not associated to the facility and does not have active fingerprints clearances in place. This poses an immediate health and safety risk to residents in care. As a result civil penalties are being assessed on this day at $100 x 2 = $200. $100 for each regulation violated.

The following updated forms are requested to be submitted to CCLD by 07/10/2024:

• Copy of updated Administrator Certificates
• Copy of facility's certificate of liability insurance
• LIC308 Designation of responsible staff person
• LIC400 Affidavit Regarding Client/Resident Cash Resources
• LIC610E Emergency Disaster Plan
• LIC500 Staff Schedule
• Copy of control of property

Citations issued on attached LIC809D. Report is reviewed with Caregiver - Talica Matainisiga and a copy is provided.
SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8865
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:

DATE: 07/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 07/03/2024 12:37 PM - 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066


FACILITY NAME: M. S. CARE HOME
FACILITY NUMBER: 415600534

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/03/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/04/2024
Section Cited
CCR
87355(e)(2)

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87355(e)(2) Criminal Record Clearance - All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c). This requirement was not met as evidenced by:
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The facility shall ensure to submit a criminal record clearance transfer request to the licensing office for S1 and S2 by the POC due date. Also submit proof of correction and a written plan outlining how this violation will be avoided in the future to licensing office by due date.
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Based on records review, licensee failed to request a transfer of criminal record clearance for S2 which poses an immediate health and safety risk to clients in care. It is confirmed that S2 is not associated to the facility on this day 07/03/2024.
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Immediate civil penalty of $100 for S2 is being assessed on this day.
Type A
07/04/2024
Section Cited
CCR87355(e)(1)

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87355(e)(1) Criminal Record Clearance - (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department. This requirement was not met as evidenced by:
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Administrator shall ensure to submit proof of fingerprinting of S2 and proof of clearance to the licensing office for S2 by the POC due date. Also submit proof of correction and a written plan outlining how this violation will be avoided in the future to licensing office by due date.
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Based on records review, licensee failed to obtain a criminal record clearance for S2 which poses an immediate health and safety risk to clients in care. It is confirmed that S2 does not have a criminal record clearance on this day 07/03/2024
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Immediate civil penalty of $100 for S2 is being assessed on this day.
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: April CowanTELEPHONE: (650) 266-8865
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:
DATE: 07/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/03/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3