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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600750
Report Date: 07/10/2024
Date Signed: 07/10/2024 02:33:21 PM


Document Has Been Signed on 07/10/2024 02:33 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: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:
07/10/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Administrator - Mercy MoreiraTIME COMPLETED:
03:00 PM
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On 07/03/2024, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced annual inspection. LPA met with administrator Mercy Moreira and explained the purpose of today's visit. There is 3 staff and 6 residents present. One of which is the administrator.

LPA was allowed entry into the facility. This is a single level facility that is cleared to be all non-ambulatory residents and up to four hospice residents. There are 2 residents on hospice at this time. The physical plant was toured inside and outside to ensure the safety of the residents. LPA observed the facility kitchen which is clean and observed appliances are in good repair. Knives are stored and locked in the medication room adjacent to the kitchen. Medications are observed to be locked in a medication room which appeared organized and well kept. Perishable and non-perishable food items are observed as in place. There is an additional refrigerator and freezer in the garage area which also carry additional food supplies. First aid kit is observed as complete with required items. LPA observed that there are two fire extinguishers in place with an inspection date of 05/13/2024, smoke detector/carbon monoxide detectors are observed in place through out the facility, and central heating/cooling system in place. PPE and additional incontinence supplies are in place in the facility garage. Laundry area is also observed as fully operational located in the garage. Emergency exit routes are observed inside and outside to be free and clear of obstructions. Last emergency/disaster drill was conducted on 05/10/2024. Water temperature was measured at 105F in a common full bathroom adjacent to the living room. Shower floors use non-skid mat when shower is in use. LPA observed rooms at random and all appeared clean, free of odors, and contained all the required furniture per regulatory recommendations. Resident linen supplies are observed as in place in a hallway closet adjacent to the living room.

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SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8865
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:
DATE: 07/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/10/2024
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 2


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: JUDY'S HOMES FOR THE ELDERLY, INC.
FACILITY NUMBER: 415600750
VISIT DATE: 07/10/2024
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LPA reviewed 2 resident files and also reviewed 3 staff files on this day. Per resident files reviewed they are current. Per staff files reviewed all files were current with training and CPR/First Aid. P&I is not handled by the facility. Client medications are inspected and are current including facility medication administration records. Administrator certificate is observed as current expiring on 05/29/2025.

The following updated forms are requested to be submitted to CCLD by 07/17/2024:

• Copy of control of property or lease agreement

No citations issued on this day. Report is reviewed with Mercy and a copy is provided.
SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8865
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:

DATE: 07/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2024
LIC809 (FAS) - (06/04)
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