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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600739
Report Date: 04/29/2024
Date Signed: 04/29/2024 12:57:51 PM

Document Has Been Signed on 04/29/2024 12:57 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
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:MARTHA'S HOMEFACILITY NUMBER:
415600739
ADMINISTRATOR/
DIRECTOR:		RUBIN, MARIETTAFACILITY TYPE:
740
ADDRESS:227 PRAGUE STREETTELEPHONE:
(650) 340-8821
CITY:SAN MATEOSTATE: CAZIP CODE:
94401
CAPACITY: 3CENSUS: 3DATE:
04/29/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Rowena Amor and Marietta RubinTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
NARRATIVE
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LPA Audrey Jeung toured facility and grounds, including detached storage shed. There are 3 client bedrooms and 2 full bathrooms. No accessible bodies of water or fire safety hazards observed. Infection Control Plan is maintained. 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 is one resident present, and 1 staff. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed, as well as staff records. Marietta Rubin is a certified RCFE administrator that oversees facility operations. Clients' records, including medications, are reviewed.

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
• LIC610E Emergency Disaster Plan (Page 9)


Deficiency of the RCFE California Code of Regulations, Title 22, Division 6, Chapter 8 is observed and cited on a following page. Also, see Technical Violations, 3 pages..
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Audrey Jeung
LICENSING EVALUATOR SIGNATURE: DATE: 04/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/29/2024
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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Document Has Been Signed on 04/29/2024 12:57 PM - It Cannot Be Edited


Created By: Audrey Jeung On 04/29/2024 at 12:27 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: MARTHA'S HOME
FACILITY NUMBER: 415600739

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87606(c)
Care of Bedridden Residents
(c) To accept or retain a bedridden person, other than for a temporary illness or recovery from surgery, a facility shall obtain and maintain an appropriate fire clearance as specified in Section 87202(a).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on client record review, the licensee did not comply with the section cited above, as one out of 3 residents is bedridden and on hospice, and resides in a room approved by fire department for non-ambulatory residents. Facility is licensed for non-ambulatory residents only. Per MD report for client #2 dated 1/24, client is bedridden.
This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/30/2024
Plan of Correction
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Proof/plan of correction to address Client #2 bedridden status to be sent to CCLD BY DUE DATE.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME:Cara Smith
LICENSING EVALUATOR NAME:Audrey Jeung
LICENSING EVALUATOR SIGNATURE:
DATE: 04/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/29/2024


LIC809 (FAS) - (06/04)
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