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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600837
Report Date: 12/06/2023
Date Signed: 12/06/2023 03:24:46 PM


Document Has Been Signed on 12/06/2023 03:24 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:COMPLETE SENIOR LIVING, INCFACILITY NUMBER:
415600837
ADMINISTRATOR:FRAGIACOMO, VIVIANFACILITY TYPE:
740
ADDRESS:601 N. IDAHOTELEPHONE:
(650) 579-1234
CITY:SAN MATEOSTATE: CAZIP CODE:
94401
CAPACITY:6CENSUS: 5DATE:
12/06/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Vivian FragiacomoTIME COMPLETED:
03:30 PM
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On this day, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced required 1 year annual inspection visit. LPA met with administrator Vivian Fragiacomo and explained the purpose of today's visit.

LPA was allowed entry into the facility. This is a one level facility. Annual Fees are 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 in the kitchen locked in a drawer adjacent to the sink. Cleaning solutions are also locked below the sink. Perishable and non-perishable food items are observed as in place. LPA observed the medications as in place and locked in a hallway closet. The first aid kit observed as complete with required items. LPA observed that the facility is equipped with full sprinkler system, fire extinguishers are placed through out the facility inspected 04/13/23, smoke detector/carbon monoxide detectors are observed in place, and central heating system. PPE and additional food supplies are observed as in place in the 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. Water temperature was measured at 118F. LPA observed several resident rooms at random and all rooms appeared clean, free of odors, and contained all the required furniture per regulatory recommendations. Cleaning supplies are observed locked below kitchen sink and in the garage. COVID PPE and resident incontinence supplies are observed in place in the garage.

This annual inspection be continued at a later date.

Report is reviewed with Vivian. No citations issued.
SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8865
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:
DATE: 12/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/06/2023
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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