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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600798
Report Date: 06/12/2024
Date Signed: 06/12/2024 02:57:08 PM


Document Has Been Signed on 06/12/2024 02:57 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:CORTEZ HOMEFACILITY NUMBER:
415600798
ADMINISTRATOR:UCOL, ANTOLIN G.FACILITY TYPE:
740
ADDRESS:1799 SHOREVIEW AVENUETELEPHONE:
(650) 375-8972
CITY:SAN MATEOSTATE: CAZIP CODE:
94401
CAPACITY:6CENSUS: 4DATE:
06/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Administrator - Anolin UcolTIME COMPLETED:
03:00 PM
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On 06/10/2024, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced infection control annual inspection. LPA met with administrator Antolin Ucol and explained purpose of today's inspection. There are 3 staff present and no clients as they are out at day program. At 2:05pm one client returned from day program.

LPA was allowed entry into the facility. This is a single level facility. Annual fees are not current. 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 a garage storage cabinet. Perishable and non-perishable food items are observed as in place. There are additional refrigerators and freezers in the garage areas which also carry additional food supplies. LPA observed the medications as in place and locked in a drawer in the living room. First aid kit is observed as complete with required items. LPA observed that there are multiple two extinguishers in place through out the facility last inspected on 05/03/2024, smoke detector/carbon monoxide detectors are observed in place through out the facility, and central heating/cooling system. Facility is also equipped with fire pull alarm. PPE and additional food supplies are observed as in place. Laundry area is also observed as fully operational located in the garage area. Emergency exit routes are observed inside and outside to be free and clear of obstructions. Water temperature was measured at 107F in a resident bathroom. Bathtubs observed are equipped with non-skid mats. LPA observed all client 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. Disaster drills take place monthly per records observed. Last taking place on 03/13/2024.

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SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8865
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:
DATE: 06/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/12/2024
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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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: CORTEZ HOME
FACILITY NUMBER: 415600798
VISIT DATE: 06/12/2024
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LPA reviewed 2 client files and also reviewed 3 staff files on this day. All files are current per review made. P&I is handled by the facility and current per the records reviewed. Client medications are inspected and are current including facility medication administration records. Administrator certificate is observed as current expired on 11/18/2023 but has submitted the renewal has been sent and payment has been received.

LPA informed the administrator that facility fees are not current. He says he will notify licensee that it needs to be paid.

The following updated forms are requested to be submitted to CCLD by 06/19/2024:

• Copy of updated Administrator Certificate
• Updated surety bond with expiration date
• LIC308 Designation of responsible staff person
• LIC400 Affidavit Regarding Client/Resident Cash Resources
• LIC402 Surety Bond
• LIC610D Emergency Disaster Plan
• LIC500 Staff Schedule
• Copy of control of property such as lease agreement with expiration date

No citations issued. Report is reviewed with administrator Antolin. Copy is provided.
SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8865
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:

DATE: 06/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2024
LIC809 (FAS) - (06/04)
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