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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600798
Report Date: 05/06/2025
Date Signed: 05/06/2025 06:06:22 PM

Document Has Been Signed on 05/06/2025 06:06 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/
DIRECTOR:		UCOL, ANTOLIN G.FACILITY TYPE:
740
ADDRESS:1799 SHOREVIEW AVENUETELEPHONE:
(650) 375-8972
CITY:SAN MATEOSTATE: CAZIP CODE:
94401
CAPACITY: 6CENSUS: 4DATE:
05/06/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:P.J. Mariano, Anaraar ManlaTIME VISIT/
INSPECTION COMPLETED:
06:15 PM
NARRATIVE
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LPA Audrey Jeung toured facility and grounds, including offices in the rear unit and detached storage shed. There are 3 client bedrooms--one with full private bathroom--two staff rooms--one for 2 staff with full private bathroom and the other for 4 staff--a common bathroom, living/dining area, family room, kitchen, and 2-car garage, where washer and dryer are located. There are no accessible bodies of water or fire safety hazards observed. Medications, toxins and sharps are stored appropriately and inaccessible to clients, a comfortable temperature is maintained, and lighting is sufficient for comfort and safety. Toilet and bathing facilities are equipped with grab bars and nonskid flooring material. Hot water temperature is tested at 111 degrees in front client bathroom. Food supply and first-aid kit are inspected. Client files are reviewed, including Centrally Stored Medications Records. A Disaster and Mass Casualty Plan is posted. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed, as well as staff training records. Anaraar Manla is a certified RCFE administrator (x 1/27) that oversees facility operations. WRITTEN NOTIFICATION OF NEWLY DESIGNATED ADMINISTRATOR TO BE SENT TO CCLD, WITH QUALIFICATIONS.

The following information/documents are requested to be sent to CCL by 5/20/25:

• LIC 400 Affidavit Regarding Client/Resident Cash Resources
• LIC 500 Personnel Report
• Proof of control of property (signed and dated lease agreement between landlord and licensee/tenant)
• Personnel Policies in facility's plan of operation

Deficiencies of the RCFE California Code of Regulations, Title 22, Division 6, Chapter 8 are observed and cited on following pages. See also Technical Advisory Notes--6 pages.
NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: Audrey Jeung
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/06/2025
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 05/06/2025 06:06 PM - It Cannot Be Edited


Created By: Audrey Jeung On 05/06/2025 at 05:20 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: CORTEZ HOME
FACILITY NUMBER: 415600798

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/06/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)(3)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on review of staff records, the licensee did not comply with the section cited above in 2 out of 6 staff records reviewed, which poses an immediate health, safety or personal rights risk to persons in care.
- New administrator staff #1 and staff #2 do not have criminal record clearances associated to this facility. Staff #1 was designated as administrator 30 days ago and staff #2 sleeps at facility but does not work here.
Civil penalties are assessed at $100 each.
POC Due Date: 05/07/2025
Plan of Correction
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Written Criminal Record Clearance transfer requests will be submitted to CCLD BY DUE DATE OR criminal records for staff #1 and #2 will be transferred in Guardian application.
Section Cited
Deficient Practice Statement
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4
POC Due Date:
Plan of Correction
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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:
Audrey Jeung
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/06/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/06/2025 06:06 PM - It Cannot Be Edited


Created By: Audrey Jeung On 05/06/2025 at 05:20 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: CORTEZ HOME
FACILITY NUMBER: 415600798

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/06/2025

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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4
Based on staff records review, the licensee did not comply with the section cited above in 4 out of 4 staff records reviewed, which poses a potential health, safety or personal rights risk to persons in care.
- There is no evidence that staff received 4 hours of annual training on postural supports, restricted health conditions and hospice care.
POC Due Date: 05/20/2025
Plan of Correction
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Staff will receive 4 hours of annual training on postural supports, restricted health conditions and hospice care and proof of training will be sent to CCLD BY DUE DATE
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
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: 05/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/06/2025


LIC809 (FAS) - (06/04)
Page: 4 of 7
Document Has Been Signed on 05/06/2025 06:06 PM - It Cannot Be Edited


Created By: Audrey Jeung On 05/06/2025 at 05:20 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: CORTEZ HOME
FACILITY NUMBER: 415600798

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/06/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.626(a)(2)
Other Provisions
(a) All residential care facilities for the elderly shall meet the following training requirements, as described in Section 1569.625, for all direct care staff: (2) Eight hours of in-service training per year on the subject of serving residents with dementia. This training shall be developed in consultation with individuals or organizations with specific expertise in dementia care or by an outside source with expertise in dementia care. In formulating and providing this training, reference may be made to written materials and literature on dementia and the care and treatment of persons with dementia. This training requirement may be satisfied in one day or over a period of time. This training requirement may be provided at the facility or offsite and may include a combination of observation and practical application.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on review of staff training records, the licensee did not comply with the section cited above in 4 out of 4 staff records reviewed, which poses a potential health, safety or personal rights risk to persons in care.
- There is no evidence that staff received 8 hours of annual dementia training.
POC Due Date: 05/20/2025
Plan of Correction
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Staff will receive at least 8 hours of annual dementia training and proof of training 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:
Audrey Jeung
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/06/2025


LIC809 (FAS) - (06/04)
Page: 5 of 7
Document Has Been Signed on 05/06/2025 06:06 PM - It Cannot Be Edited


Created By: Audrey Jeung On 05/06/2025 at 05:20 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: CORTEZ HOME
FACILITY NUMBER: 415600798

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/06/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.69(b)
Other Provisions
(b) Each employee who received training and passed the examination required in paragraph (5) of subdivision (a), and who continues to assist with the self-administration of medicines, shall also complete eight hours of in-service training on medication-related issues in each succeeding 12-month period.

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 4 out of 4 staff records reviewed, which poses a potential health, safety or personal rights risk to persons in care.
- There is no documentation that Staff #3, #4, #5, #6 received required 8 hours of annual medications training. Two hours of medication training was provided in Feb. 2024 and 3 hours was provided in April 2024.
POC Due Date: 05/20/2025
Plan of Correction
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Staff will receive at least 8 hours of annual medications training, and proof of training will be sent to CCLD BY DUE DATE.
Type B
Section Cited
CCR
87458(c)(1)
Medical Assessment
(c) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the licensed medical professional's diagnosis or diagnoses and results of an examination for all of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on review of clients' records, the licensee did not comply with the section cited above in 1 out of 4 client records, which poses a potential health, safety or personal rights risk to persons in care.
- There is no primary diagnosis indicated on MD report of client #2
POC Due Date: 05/20/2025
Plan of Correction
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Written primary diagnosis of client #2 by MD will 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:
Audrey Jeung
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/06/2025


LIC809 (FAS) - (06/04)
Page: 6 of 7
Document Has Been Signed on 05/06/2025 06:06 PM - It Cannot Be Edited


Created By: Audrey Jeung On 05/06/2025 at 05:20 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: CORTEZ HOME
FACILITY NUMBER: 415600798

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/06/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) 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 requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on record review, the licensee did not comply with the section cited above, as Emergency Disaster Drill has not been conducted for the current year. Last documentation of emergency drill was in December 2024. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/20/2025
Plan of Correction
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4
Disaster drill will be conducted and documentation to be sent to CCLD BY DUE DATE.
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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2
3
4
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: 05/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/06/2025


LIC809 (FAS) - (06/04)
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