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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600837
Report Date: 01/21/2025
Date Signed: 01/21/2025 05:45:39 PM

Document Has Been Signed on 01/21/2025 05:45 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: 5DATE:
01/21/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:45 PM
MET WITH:Non Dladla and Vivian FragiacomoTIME VISIT/
INSPECTION COMPLETED:
06:00 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 at 116 degrees. 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 5 residents present and 3 staff. Two residents receive hospice services. Client records are reviewed. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed. Other required staff records--including current first aid training and health screenings--will be reviewed at a later date. Vivian Fragiacomo is a RCFE administrator (x 11/24) that has submitted education certificates for renewal of administrator certificate.

The following information/forms are requested to be submitted to CCLD BY 2/4/25:

- Administrative Organization (LIC309)
- Designation of Administrative Responsibility (LIC308)
- Personnel Report (LIC500)
- Emergency Disaster Plan (LIC610D)
- Bedridden plan of operation
- Proof of current liability insurance
- Infection Control Plan (LIC9282)

Deficiencies of the RCFE California Code of Regulations, Title 22, Division 6, Chapter 8 are observed and cited on following page.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Audrey Jeung
LICENSING EVALUATOR SIGNATURE: DATE: 01/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/21/2025
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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Document Has Been Signed on 01/21/2025 05:45 PM - It Cannot Be Edited


Created By: Audrey Jeung On 01/21/2025 at 05:10 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: 01/21/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/22/2025
Section Cited
CCR
87355(c)

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CRIMINAL RECORD CLEARANCE
A licensee or applicant for a license may request a transfer of a criminal record clearance from one state licensed facility to another...by providing....to the Department.
This requirement is not met, as staff #1 has been working for a month, but criminal record
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Criminal record clearance transter request shall be sent to CCLD with photo ID.
Proof of correction to be sent to CCLD BY DUE DATE
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clearance has not been associated to this facility. Licensee failed to ensure that all staff maintain criminal record clearance & association to facility. This poses an immediate health, safety, or personal rights risk to clients in care.
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Type A
01/22/2025
Section Cited
CCR87608(a)(5)

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POSTURAL SUPPORTS
Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.
This requirement is not met, as full bed rails
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Full bed rails will be removed or reduced to half size. Proof of correction to be sent to CCLD BY DUE DATE
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are used for client #2 in room 2. Licensee failed to prohibit use of full bed rails, which poses an immediate health, safety or personal rights risk to clients in care.
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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.
SUPERVISOR'S NAME:April Cowan
LICENSING EVALUATOR NAME:Audrey Jeung
LICENSING EVALUATOR SIGNATURE:
DATE: 01/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/21/2025


LIC809 (FAS) - (06/04)
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