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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600750
Report Date: 07/11/2022
Date Signed: 07/11/2022 11:00:16 AM


Document Has Been Signed on 07/11/2022 11:00 AM - It Cannot Be Edited

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:JUDY'S HOMES FOR THE ELDERLY, INC.FACILITY NUMBER:
415600750
ADMINISTRATOR:ROIAS, JUDYFACILITY TYPE:
740
ADDRESS:3415 PACIFIC BLVD.TELEPHONE:
(650) 458-3262
CITY:SAN MATEOSTATE: CAZIP CODE:
94403
CAPACITY:6CENSUS: 6DATE:
07/11/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Mercy MoreiraTIME COMPLETED:
11:00 AM
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On this day Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced infection control annual inspection. LPA met with caregiver Criselda and explained purpose of today's inspection. Later during the visit the facility administrator Mercy Moreira arrived at the facility at 1020hrs.

LPA toured the physical plant inside and out. There are no accessible bodies of water or fire safety hazards observed. COVID postings and hand washing signs are present inside the facility but not on the main entrance. Hand sanitizer is observed as readily available through out the facility. Infection control practices are reviewed: entry procedures, staff training and policies, resident monitoring, containment strategies, environmental preparation and cleaning. PPE supply is observed as in place. Medications, toxins and sharps are stored appropriately and inaccessible to clients. Facility ambient temperature is warm and comfortable, and lighting is sufficient for residents and staff safety. Toilet and bathing facilities are equipped with grab bars and not slip mats Liquid soap is available. Paper towels are present in half bathroom and full bathroom. Water temperature is tested in hallway bathroom at 107F. First-aid kit is inspected and is complete. A disaster and mass casualty plan is present and current. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been finger print cleared and associated to the facility. Administrator certificate is viewed as current expiring 5/29/2023. Mitigation plan is reviewed with the administrator. Facility does not handle resident P&I monies. Staff first aid cards are inspected as current and COVID vaccine and boosters are current for staff and residents. LPA requested an updated LIC308 to be sent to the Department by 7/18/2022 to the attention of LPA Vado.

LPA received the following updated items during today's inspection:
• Copy of administrator Certificate
• LIC 500 Personnel Report
• LIC 610E Personnel Report

Report is reviewed with administrator.

No deficiencies cited today.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:
DATE: 07/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/11/2022
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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