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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600837
Report Date: 01/14/2026
Date Signed: 01/14/2026 06:59:57 PM

Document Has Been Signed on 01/14/2026 06:59 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/
DIRECTOR:		FRAGIACOMO, VIVIANFACILITY TYPE:
740
ADDRESS:601 N. IDAHOTELEPHONE:
(650) 579-1234
CITY:SAN MATEOSTATE: CAZIP CODE:
94401
CAPACITY: 6CENSUS: 6DATE:
01/14/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:00 PM
MET WITH:Vivian FragiacomoTIME VISIT/
INSPECTION COMPLETED:
07:00 PM
NARRATIVE
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LPA Audrey Jeung toured facility and grounds of this 1-level home, consisting of 6 client bedrooms--all with half bathrooms and exit doors--one staff break room, one common half bathroom, one full bathroom for staff, office, kitchen, living and dining rooms. There is a fenced and level backyard and wooden deck around the sides and back of building. Washer and dryer are located in one car garage. No accessible bodies of water or fire safety hazards observed. PPE supply is inspected. Fresh and non-perishable food supplies are maintained. A comfortable temperature is maintained, lighting is sufficient for comfort and safety and hot water temperature tested. Toilet and bathing facilities are equipped with grab bars and nonskid flooring material. Liquid soap is available at all sinks. First-aid kit is inspected and complete. A Disaster and Mass Casualty Plan is posted. There are 6 residents present and 3 staff. No one is receiving hospice services. Client records are reviewed. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed, including required staff records. Vivian Fragiacomo is a RCFE administrator (x 11/26) that oversees facility operations.
Due to time constraints, staff training records and clients' medication records will be reviewed at a later date.

The following information/forms are requested to be submitted to CCLD BY 1/21/26:

- Personnel Report (LIC500)
- Emergency Disaster Plan (9- page LIC610D)
- Bedridden plan of operation
- Proof of current liability insurance

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--3 pages.
NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: Audrey Jeung
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 01/14/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/14/2026
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 01/14/2026 06:59 PM - It Cannot Be Edited


Created By: Audrey Jeung On 01/14/2026 at 05:34 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: COMPLETE SENIOR LIVING, INC
FACILITY NUMBER: 415600837

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/14/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
MAINTENANCE AND OPERATION
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 requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above, as hot water temperature tested at 125 degrees in bathroom in room #5, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/15/2026
Plan of Correction
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Hot water temperature will be lowered and maintained between 105 and 120 degrees F. Proof of correction to 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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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: 01/14/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/14/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/14/2026 06:59 PM - It Cannot Be Edited


Created By: Audrey Jeung On 01/14/2026 at 06:11 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: COMPLETE SENIOR LIVING, INC
FACILITY NUMBER: 415600837

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/14/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on staff records review, the licensee did not comply with the section cited above in 1 out of 3 staff files reviewed, which poses a potential health, safety or personal rights risk to persons in care.
- There is no personnel record for staff #2, who was hired September 2025.
POC Due Date: 01/21/2026
Plan of Correction
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Staff record for staff #2 will be maintained, and proof of correction will be sent to CCLD BY DUE DATE
Type B
Section Cited
CCR
87463(a)
Reappraisals
(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated, in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on review of client records, the licensee did not comply with the section cited above in 5 out of 6 client records reviewed, which poses a potential health, safety or personal rights risk to persons in care.
) - There are no updated appraisals for clients #1, #2, #3, #6.
POC Due Date: 01/21/2026
Plan of Correction
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Signed and dated complete appraisals for clients #1, #2, #3, #6 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: 01/14/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/14/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/14/2026 06:59 PM - It Cannot Be Edited


Created By: Audrey Jeung On 01/14/2026 at 06:11 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: COMPLETE SENIOR LIVING, INC
FACILITY NUMBER: 415600837

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/14/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(h)
Reappraisals
(h) The licensee shall request that all residents receive an annual routine visit with a licensed medical professional once every twelve months, either in person or by video appointment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on review of client records, the licensee did not comply with the section cited above in 5 out of 6 client records reviewed, which poses a potential health, safety or personal rights risk to persons in care.
- Updated MD reports for clients #2, #3, #4, #5, #6 are dated more than 12 months ago or not on file.
POC Due Date: 01/21/2026
Plan of Correction
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Updated MD reports for 5 residents will be sent to CCLD BY DUE DATE.
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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Based on absence of documentation of emergency drills per administrator, the licensee did not comply with the section cited above, which poses a potential health, safety or personal rights risk to persons in care.
- There is no documentation that emergency drills are done at least quarterly.
POC Due Date: 01/21/2026
Plan of Correction
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Documentation of emergency drills 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: 01/14/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/14/2026


LIC809 (FAS) - (06/04)
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