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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600755
Report Date: 04/22/2025
Date Signed: 04/22/2025 04:16:01 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 04/22/2025 04:16 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:J AND V FAMILY CARE HOMEFACILITY NUMBER:
415600755
ADMINISTRATOR/
DIRECTOR:		ANDAYA, JULITA DFACILITY TYPE:
740
ADDRESS:329 SAN PABLO AVENUETELEPHONE:
(650) 952-5231
CITY:MILLBRAESTATE: CAZIP CODE:
94030
CAPACITY: 6CENSUS: 6DATE:
04/22/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Administrator - Julita AndayaTIME VISIT/
INSPECTION COMPLETED:
02:45 PM
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On 04/22/2025, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced required 1 year inspection. LPA met with administrator Julita Andaya and explained the purpose of today's visit. Currently there are 6 residents in place and 2 staff at time of visit. The administrator arrived later during today's visit and met with LPA.

The facility is licensed for age range 60 and over. All may be non-ambulatory. Facility has a waiver for 3 residents. Hospice resident is allowed in bedroom #2 only. There currently are 2 hospice resident in care. This is a single level facility. Facility temperature is comfortable for residents in care. Facility emergency food supplies such as canned goods are in place. Additional supplies are in the garage as well. There are 4 resident rooms. Water temperature is tested in both facility bathrooms. The water temperature is measured at 120F in the bathroom adjacent to room 1 and 130F in the other bathroom located near room 4. Cleaning supplies in the kitchen are observed as locked beneath the kitchen sink. Additional cleaning supplies are locked in the garage in a storage cabinet. Facility knives are observed to be locked in a drawer beneath below the kitchen sink. Kitchen food supplies are observed to be in place with 2 day fresh food supply and canned goods fulfilling the 7 day emergency food supply. A tour of the outside of the facility is conducted. Emergency routes are free and clear of any obstructions. No locks are observed on both gates. Smoke detectors and carbon monoxide detectors are located through out the facility. LPA observed 2 fire extinguishers in the facility. Both are observed as charged and ready for use. Facility does not have disaster drill records on file to review. Linens are in place for resident use stored in a hallway closet and in resident room closets.

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NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: Jaime Vado
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/22/2025
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 5
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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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: J AND V FAMILY CARE HOME
FACILITY NUMBER: 415600755
VISIT DATE: 04/22/2025
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LPA observed all resident rooms and observed that they contain the required furniture and lighting as outlined in Title 22. Medications, first aid kit, are stored in a locked medication cabinet in the kitchen. Toilet and bathing facilities are equipped with grab bars and nonskid flooring material. Hygiene supplies are in place. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed as current. LPA reviewed staff and resident files on this day. Resident # 5 and #6 physician's report is observed to be out of date with no current assessments or updates on file. Both residents have dementia diagnosis. Staff training records are observed to be current and in place. Administrator certificate for Julita Andaya is observed as expired as of 01/23/2025 but has submitted renewal items and new certification is processing.

Report is reviewed with Julita Andaya. A copy of this report is provided to the facility.

Deficiencies of the RCFE California Code of Regulations, Title 22, Division 6, Chapter 8 are observed and cited on following pages. Also, see Advisory Notes--7 pages--for technical violations to be addressed.
NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: Jaime Vado
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2025
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 04/22/2025 04:16 PM - It Cannot Be Edited


Created By: Jaime Vado On 04/22/2025 at 11:37 AM
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: J AND V FAMILY CARE HOME
FACILITY NUMBER: 415600755

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/22/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/23/2025
Section Cited
CCR
87303(e)(2)

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MAINTENANCE AND OPERATION
Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). This regulation has not been met as evidenced by:
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Facility shall develop a plan to ensure that the hot water temperature will be lowered and maintained between 105 and 120 degrees.
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Based on observations made, the licensee did not comply with the section cited above, as hot water temperature in clients' bathroom tested at 130 degrees F, which poses an immediate health, safety or personal rights risk to persons in care.
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Proof of correction to be sent to CCLD BY DUE DATE.
Type B
04/29/2025
Section Cited
HSC1569.695(c)

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ยง1569.695 (c) Emergency Plans - A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.This health and safety code has not been met as evicenced by:
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The facilty shall develop a plan to conduct drills quarterly. This plan and updated disaster drill log is to be maintained at all times.
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Based on facility records reviewed, and discussion with administrator, the facility does not have a record of the last emergency drill conducted. This poses a potential health and safety risk to residents in care.
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Proof of correction to be sent to CCLD BY DUE DATE.
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:
Jaime Vado
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/22/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/22/2025 04:16 PM - It Cannot Be Edited


Created By: Jaime Vado On 04/22/2025 at 01:05 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: J AND V FAMILY CARE HOME
FACILITY NUMBER: 415600755

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/22/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/29/2025
Section Cited
CCR
87506(a)

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87506(a) Resident Records. A separate, complete, and current record shall be maintained for each resident in the facility, readily available to facility staff and to licensing agency staff and shall contained specified information. This regulation has not been met as evidenced by:
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Facility shall ensure that all residents with dementia have either a current physicians report or other assessment showing the resident has no change from last physician's report.
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Based on resident files reviewed, resident #5 and #6 do not have current physicians reports. Both residents reports are over 1 year old with no updated assessments or reports on file. This poses a potential health and safety risk for residents in care.
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Proof of correction to be sent to CCLD BY DUE DATE.

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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.
April Cowan
NAME OF LICENSING PROGRAM MANAGER:
Jaime Vado
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/22/2025


LIC809 (FAS) - (06/04)
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