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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600885
Report Date: 03/08/2024
Date Signed: 03/08/2024 12:27:38 PM

Document Has Been Signed on 03/08/2024 12:27 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
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:MAXIM RESIDENTIAL HOMEFACILITY NUMBER:
415600885
ADMINISTRATOR:SAVOI EGBEFACILITY TYPE:
735
ADDRESS:118 N. HUMBOLDT ST.TELEPHONE:
(650) 376-3285
CITY:SAN MATEOSTATE: CAZIP CODE:
94401
CAPACITY: 4CENSUS: 4DATE:
03/08/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Savoi EgbeTIME COMPLETED:
12:30 PM
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LPA Jeung toured facility and grounds, including detached garage, where washer and dryer are located. Delayed egress front door is tested and operable; auditory alarm sounded for 15 seconds and then opened after 15 seconds.
There are no accessible bodies of water or fire safety hazards observed. Medications, toxins and sharps are stored appropriately and inaccessible to clients, and a comfortable temperature is maintained. Bathing facilities are equipped with grab bars and nonskid flooring material. Hot water temperature is tested at 111 degrees in clients' bathroom. Food and PPE supplies and first-aid kit are inspected. Client files were reviewed on 8/15/23 during last inspection. Medications are recorded on Centrally Stored Medications Records, provided by pharmacy. A Disaster and Mass Casualty Plan is posted.

Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed, as well as staff training records. LPA interviewed a resident. Savoi Egbe is a certified RCFE administrator (x 4/24) that oversees facility operations.

The following forms are requested to be updated and returned to CCL by 3/22/24:
• LIC 500 Personnel Report
• LIC 309 Administrative Organization

Administrator is reminded to review Emergency Disaster Plan (revised 9 page version) annually and sign the last page.

No deficiencies of the ARF California Code of Regulations, Title 22, Division 6, Chapter 8 are observed.
See two Advisory Notes for technical violations.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Audrey Jeung
LICENSING EVALUATOR SIGNATURE: DATE: 03/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/08/2024
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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