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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600742
Report Date: 05/13/2025
Date Signed: 05/13/2025 01:54:55 PM

Document Has Been Signed on 05/13/2025 01:54 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:PATRICIA HOMEFACILITY NUMBER:
415600742
ADMINISTRATOR/
DIRECTOR:		NAVARRO, AURELIAFACILITY TYPE:
740
ADDRESS:988 PATRICIA AVENUETELEPHONE:
(650) 347-3870
CITY:SAN MATEOSTATE: CAZIP CODE:
94401
CAPACITY: 6CENSUS: 5DATE:
05/13/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Irene Lagua and Aurelia NavarroTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
NARRATIVE
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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 3 live-in staff. There is a detached storage shed in backyard. Washer and dryer are located in one car attached garage.
Staff confirmed that facility is currently COVID free. PPE and food supplies are 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. Hot water temperature tested at 111 degrees in clients' bathroom. 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 3 residents present, and 3 staff; other clients are participating in day programming off site. Criminal record clearances or exemptions for facility staff or other individuals who have client contact are reviewed, as well as other staff and client records. Personal and incidental cash transaction records are maintained accurate, including safeguarded cash for 4 residents. Aurelia Navarro is a certified RCFE administrator (x 9/25) that oversees facility operations.

- Administrative Organization (LIC309) is requested to be updated and submitted to CCLD by 5/27/25:

The following information is provided to LPA today:
- Proof of current liability insurance
- Proof of current surety bonding.

Deficiencies of the General Licensing Regulations, of the California Code of Regulations, Title 22, Division 6, are cited. Also see Technical Advisory Notes--1 page--for additional information.
NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: Audrey Jeung
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/13/2025
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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Document Has Been Signed on 05/13/2025 01:54 PM - It Cannot Be Edited


Created By: Audrey Jeung On 05/13/2025 at 01:14 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: PATRICIA HOME
FACILITY NUMBER: 415600742

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/13/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on review of staff training records, the licensee did not comply with the section cited above in 1 out of 4 staff records reviewed, which poses a potential health, safety or personal rights risk to persons in care.
- There is no proof that relief staff #4 has received 20 hours of annual training, including 4 hours of training on postural supports, restricted health conditions and hospice care.
POC Due Date: 05/27/2025
Plan of Correction
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Proof of annual 20 hours of training for staff #4 will be sent to CCLD, including 4 hours of training on postural supports, restricted health conditions and hospice care, by DUE DATE
Type B
Section Cited
CCR
87608(a)(5)
POSTURAL SUPPORTS
Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Under no circumstances shall postural supports include tying, depriving, or limiting the use of a resident's hands or feet.

Based on observation, the licensee did not comply with the section cited above, as client #1 is observed wearing thick white padded mitts on both hands, which poses a potential health, safety or personal rights risk to persons in care.
Mitts are secured at wrists, and client is blind and unable to use hands.
POC Due Date: 05/27/2025
Plan of Correction
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Exception request to use mitts on client #1 will be submitted to CCLD BY DUE DATE, Supportive documents to include MD report/assessment, appraisal addressing use of mitts and why client wears mitts, recommendations from behaviorist and/or medical professional for client to wear mitts, consent letter(s) from client's responsible party or placement team.
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:
Audrey Jeung
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/13/2025


LIC809 (FAS) - (06/04)
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