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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600534
Report Date: 07/19/2022
Date Signed: 07/19/2022 11:23:04 AM


Document Has Been Signed on 07/19/2022 11:23 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
CCLD Regional Office, 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: 4DATE:
07/19/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Caregiver, Talica MatainisigaTIME COMPLETED:
11:30 AM
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 July 19, 2022, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced annual infection control inspection. LPA met with Caregiver, Talica Matainigia and explained the purpose of the visit. Upon arrival LPA observed the COVID-19 signage posted on the front door. LPA Charitra was screened at entry point and Caregiver was able to provide LPA with screening log documentation for staff, residents and visitors.

LPA toured facility and grounds. No accessible bodies of water or fire safety hazards observed. This is a 6 bedroom home with 4 half baths and 2 full baths. All bathrooms are observed to be equipped with liquid soap, paper towels, covered trash can, and hand washing signs. LPA advised caregiver to remove hand-towels from the communal bathrooms. Infection control practices are present: entry procedures, COVID signage, face coverings, daily monitoring for residents and staff, and 30-day PPE supply.

LPA observed the garage to be locked and inaccessible to residents. Washer and dryer was observed to be in good, working condition. Extra food supply was observed in the garage.

LPA toured the living room and dining room and it was clear and free from any tripping hazards. A comfortable temperature was maintained, lighting is sufficient. LPA toured the kitchen; medications, toxins and sharps are stored appropriately and inaccessible to residents. LPA observed 2 day perishable and 7 day non-perishable present. LPA advised caregiver to remove hand-towels from the kitchen. First aid kit was observed to be completed. Extra linen was observed to be present. During the visit 3 residents were seated on the dining room table maintaining social distancing.

LPA requests the following forms to be send to CCLD by 7/26/22:
• Administrator Certificate
• LIC 308 Designation of Administrative Responsibility
• LIC 500 Personnel Report
• LIC 610E Emergency Disaster Plan

No citations issued during this visit. LPA reviewed report with Caregiver, and a copy is provided.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 07/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/19/2022
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