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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600534
Report Date: 07/24/2025
Date Signed: 07/24/2025 02:02:12 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 07/24/2025 02:02 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/
DIRECTOR:		STEFANAC, SUZIFACILITY TYPE:
740
ADDRESS:435 PORTOLA DRIVETELEPHONE:
(650) 345-6456
CITY:SAN MATEOSTATE: CAZIP CODE:
94403
CAPACITY: 6CENSUS: 4DATE:
07/24/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Caregiver - Talica MatainsigaTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
NARRATIVE
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On 07/24/2025, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced annual inspection. LPA met with caregiver Talica Matainsiga and explained the purpose of today's visit. There are 2 staff present and 4 residents in the facility during today's inspection.

This is a single level facility. Annual fees are current. The facility is licensed for residents 59 and over which all may be non-ambulatory. Two residents are on hospice during today's visit. 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 05/20/2025, 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.

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April CowanTELEPHONE: (650) 266-8865
Jaime VadoTELEPHONE: (559) 476-9353
DATE: 07/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/24/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: 07/24/2025
NARRATIVE
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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 110F. 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. Per staff, the facility conducted a disaster drill in March of 2025 but did not document this drill and the facility does not maintain a disaster training log.

LPA reviewed 4 resident files and reviewed 3 staff files on this day. Per resident files reviewed, some files are not current. R1 with dementia does not have a current appraisal on file, last appraisal was in February 2024. R3 and R4 both do not have current appraisals or updated LIC602 since 2023. 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 dating back to 2017 and needs to be updated with current items such as administrator certificate and first aid card. LPA cannot locate a current administrator certificate, recertification documents, or first aid training on record for the administrator during today's visit.

The following updated forms are requested to be submitted to CCLD by 07/31/2025:

• Copy of updated Administrator Certificate
• Copy of facility's certificate of liability insurance
• LIC308 Designation of responsible staff person
• LIC610E Emergency Disaster Plan
• LIC500 Staff Schedule
• Copy of control of property

Citations issued on attached LIC809D and technical violation issued on attached LIC9102TV. 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: 07/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2025
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 07/24/2025 02:02 PM - It Cannot Be Edited


Created By: Jaime Vado On 07/24/2025 at 12:03 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 07/24/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/31/2025
Section Cited

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87463 Reappraisals: (h) The licensee shall request that all residents receive an annual routine visit with a licensed medical professional once every twelve months, either in person or by video appointment. This requirement has not been met as evidenced by:
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Based on resident file review conducted, 3 of 4 resident files are observed to not have current appraisals. R1 with dementia does not have a current appraisal on file, last appraisal was in February 2024. R3 and R4 both do not have current appraisals or updated LIC602 since 2023.
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Type B
07/31/2025
Section Cited

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(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of individuals served by the facility is not required during a drill. While a facility may provide an opportunity for individuals served by the facility to participate in a drill, it shall not require that participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and, if applicable, the names of staff participating in the drill. This requirement is not met as evidenced by:
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Based on interview and documentation reviewed, the facility has conducted a drill but does not record each drill. LPA does not have any documentation to review indicating drills are taking place quarterly.
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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.
April Cowan
NAME OF LICENSING PROGRAM MANAGER:
TELEPHONE: (650) 266-8865
Jaime Vado
NAME OF LICENSING PROGRAM ANALYST:
TELEPHONE: (559) 476-9353
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/24/2025


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 07/24/2025 02:02 PM - It Cannot Be Edited


Created By: Jaime Vado On 07/24/2025 at 12:25 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 07/24/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/31/2025
Section Cited

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87412 Personnel Records - (d) The licensee shall maintain documentation that an administrator has met the certification requirements specified in Section 87406, Administrator Certification Requirements or the recertification requirements in Section 87407, Administrator Recertification Requirements. This regulation has not been met as evidenced by:
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Based on file revies conducted, the file for the administrator is not complete showing she holds a current administrator certificate or recertification requirements. The file is incomplete with documents dating back to 2017.
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Type B
07/31/2025
Section Cited

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87411 Personnel Requirements - General (c)(1) - Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This regulation has not been met as evidenced by:
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Based on file reviews conducted, the file for the administrator is not current with outdated items dating back to 2017. LPA cannot locate a current first aid training on file for the administrator.
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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.
April Cowan
NAME OF LICENSING PROGRAM MANAGER:
TELEPHONE: (650) 266-8865
Jaime Vado
NAME OF LICENSING PROGRAM ANALYST:
TELEPHONE: (559) 476-9353
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/24/2025


LIC809 (FAS) - (06/04)
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