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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600742
Report Date: 08/04/2022
Date Signed: 08/04/2022 02:42:05 PM


Document Has Been Signed on 08/04/2022 02:42 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:PATRICIA HOMEFACILITY NUMBER:
415600742
ADMINISTRATOR:NAVARRO, AURELIAFACILITY TYPE:
740
ADDRESS:988 PATRICIA AVENUETELEPHONE:
(650) 347-3870
CITY:SAN MATEOSTATE: CAZIP CODE:
94401
CAPACITY:6CENSUS: 5DATE:
08/04/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Irene LaguaTIME COMPLETED:
02:45 PM
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
LPA Audrey Jeung toured facility and grounds of this RCFE for developmentally disabled elderly. No accessible bodies of water or fire safety hazards are observed. There are 3 shared bedrooms for residents and 2 bathrooms--one designated for residents. As per San Mateo Fire Dept.(5/2010), exit doors in bedrooms are not required to be exits. In addition, there are 2 staff rooms for 4 live-in staff. There is a detached storage shed in backyard. Washer and dryer are located in one car attached garage.
LPA was temperature checked upon entry, and signed visitor log Staff confirmed that facility is currently COVID free. Infection control practices are reviewed: entry procedures, staff training and policies, resident monitoring, containment strategies, environmental preparation and cleaning. PPE supply is adequate and infection control signs are posted prominently. Medications, toxins and sharps are stored appropriately and inaccessible to clients, a comfortable temperature is maintained, and lighting is sufficient for comfort and safety. Soap and paper towels are present in bathrooms and kitchen sink. Toilet and bathing facilities are equipped with grab bars and nonskid flooring material. First-aid kit is inspected and complete. A Disaster and Mass Casualty Plan is posted. There are 5 residents present, and 3 staff; clients are participating in day programming from home, per Ms. Lagua. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed; first-aid training for staff is current. Aurelia Navarro is a certified RCFE administrator (x 9/23) that oversees facility operations.

The following forms/information are requested to be updated and submitted to CCLD by 8/18/22:
- Administrative Organization (LIC309)
- Designation of Administrative Responsibility (LIC308)
- Personnel REport (LIC500)
- Emergency Disaster Plan (LIC610 revised)
- Proof of current liability insurance.

No deficiencies of the General Licensing Regulations, of the California Code of Regulations, Title 22, Division 6, are cited. Facility is operating in substantial compliance.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:
DATE: 08/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/04/2022
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