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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600739
Report Date: 05/19/2021
Date Signed: 05/21/2021 11:12:03 AM

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:MARTHA'S HOMEFACILITY NUMBER:
415600739
ADMINISTRATOR:RUBIN, MARIETTAFACILITY TYPE:
740
ADDRESS:227 PRAGUE STREETTELEPHONE:
(650) 340-8821
CITY:SAN MATEOSTATE: CAZIP CODE:
94401
CAPACITY:3CENSUS: 3DATE:
05/19/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Marietta RubinTIME COMPLETED:
11:45 AM
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LPA Audrey Jeung toured facility and grounds. No accessible bodies of water or fire safety hazards observed. Infection control practices are reviewed: entry procedures, staff training and policies, resident monitoring, containment strategies, environmental preparation and cleaning. 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. Soap, paper towels and signage of proper hand washing procedures is posted at all sinks. First-aid kit is inspected and complete. An updated Disaster and Mass Casualty Plan is readily available. There are 3 residents present, and 3 staff. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed. Marietta Rubin is a certified RCFE administrator (x11/22) that oversees facility operations.

The following updated forms/information are provided to LPA:

• LIC 308 Designation of Administrative Responsibility
• LIC 309 Administrative Organization
• Proof of current Surety Bond
• LIC 500 Personnel Report
• Proof of current liability insurance

Ms. Rubin is advised that Personal Rights form (LIC613C-2) has been revised to include Health and Safety Code 1569.269, non-discrimination (LGBTQ) notice, AND Centralized Complaint and Information Bureau (CCIB) contact information. This information must be posted prominently in facility, and LIC613C-2 must be signed by resident or his/her representative.

No deficiencies of the RCFE California Code of Regulations, Title 22, Division 6, Chapter 8 are observed. Facility is operating in substantial compliance.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2021
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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