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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600837
Report Date: 01/04/2024
Date Signed: 01/04/2024 03:19:49 PM

Document Has Been Signed on 01/04/2024 03:19 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:
01/04/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Administrator - Vivian FragiacomoTIME COMPLETED:
03:30 PM
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On 01/04/2023 at 1pm, Licensing Program Analyst (LPA) conducted an unannounced case management annual continuation visit to complete the annual that was began on 12/06/2023. LPA met with administrator Vivian Fragiacomo and explained the purpose of today's visit.

During todays visit LPA conducted record reviews for 2 residents and 3 staff. Present in the facility is 6 residents and 4 staff. Two of which are agency staff. LPA reviewed the records indicated and all files reviewed are current. Administrator certificate is pending renewal and has not received the updated certificate as of this time. Administrator certificate is expired but renewal has been submitted but has not received yet. Facility does not handle resident monies.

The following updated forms are being requested to be received by 01/11/2024:

• LIC610D Emergency Disaster Plan
• LIC 308 Designation of Administrative Responsibility
• LIC 500 Personnel Report
• Updated administrator certificate
• LIC9020 Client Roster
• Certificate of Liability Insurance

There are no citations issued on this day.

Report is reviewed with Vivian.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Jaime Vado
LICENSING EVALUATOR SIGNATURE: DATE: 01/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/04/2024
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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