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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600837
Report Date: 02/10/2025
Date Signed: 02/10/2025 12:44:56 PM

Document Has Been Signed on 02/10/2025 12:44 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: 4DATE:
02/10/2025
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Noxolo Diamini and Vivian FragiacomoTIME VISIT/
INSPECTION COMPLETED:
12:45 PM
NARRATIVE
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To complete annual inspection of 1/21/25, LPA Jeung reviewed staff records and clients' Centrally Stored Medications Records.

Deficiencies of the California Code of Regulations, Title 22, are cited on a following page.



Completed Emergency Disaster Plan (LIC610E) is requested to be signed, dated and submitted to CCLD BY 2/24/25.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Audrey Jeung
LICENSING EVALUATOR SIGNATURE: DATE: 02/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/10/2025
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 02/10/2025 12:44 PM - It Cannot Be Edited


Created By: Audrey Jeung On 02/10/2025 at 11:03 AM
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: 02/10/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/24/2025
Section Cited
HSC
1569.625(b)(2)

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HEALTH AND SAFETY CODE
... training requirements shall also include an additional 20 hours annually, 8 hours of which shall be dementia care training... & 4 hours...postural supports, restricted health conditions, and hospice care, as required by...1569.696. This training shall be
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Proof of required annual training for Staff #6 on dementia, postural supports, restricted health conditions, hospice care to be sent to CCLD BY DUE DATE
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administered on the job, or in a classroom setting, or both, and may include online training. This requirement is not met, as there is no record that 1 out of 5 staff received annual training on dementia, postural supports, restricted health conditions and hospice care.
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Type B
02/24/2025
Section Cited
CCR87411(c)(1)

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PERSONNEL REQUIREMENTS - GENL
Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.
This requirement is not met, as there is no evidence that 2 out of 5 staff have current first aid training, which poses a potential
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Proof of current first aid training for staff #1 and #4 will be sent to CCLD BY DUE DATE
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health, safey or personal rights risk to clients in care.
Staff #1 and #4 do not have proof of first aid training.
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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: 02/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/10/2025


LIC809 (FAS) - (06/04)
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