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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600885
Report Date: 02/27/2025
Date Signed: 02/27/2025 06:25:33 PM

Document Has Been Signed on 02/27/2025 06:25 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:MAXIM RESIDENTIAL HOMEFACILITY NUMBER:
415600885
ADMINISTRATOR/
DIRECTOR:		SAVOI EGBEFACILITY TYPE:
735
ADDRESS:118 N. HUMBOLDT ST.TELEPHONE:
(650) 376-3285
CITY:SAN MATEOSTATE: CAZIP CODE:
94401
CAPACITY: 4CENSUS: 4DATE:
02/27/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:15 PM
MET WITH:Savoi EgbeTIME VISIT/
INSPECTION COMPLETED:
06:30 PM
NARRATIVE
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LPA Jeung toured facility and grounds, including detached garage, where washer and dryer are located. Delayed egress back 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 in clients' bathroom. Food and PPE supplies and first-aid kit are inspected. Client files are reviewed, including cash handling records. 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 three staff records. Savoi Egbe is a certified ARF administrator (x 4/26) that oversees facility operations.

The following forms are requested to be updated and returned to CCL by 3/6/25:
• LIC 500 Personnel Report
• LIC 309 Administrative Organization
• LIC 308 Designation of Administrative Responsibility



Deficiencies of the ARF California Code of Regulations, Title 22, Division 6, Chapter 8 are cited on a following page.
See Advisory Note for technical violation.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Audrey Jeung
LICENSING EVALUATOR SIGNATURE: DATE: 02/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/27/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
Document Has Been Signed on 02/27/2025 06:25 PM - It Cannot Be Edited


Created By: Audrey Jeung On 02/27/2025 at 06:04 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: MAXIM RESIDENTIAL HOME
FACILITY NUMBER: 415600885

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/27/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees 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 141 degrees in client's bathroom. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/28/2025
Plan of Correction
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Hot water temperature shall be lowered and maintained between 105 and 120 degrees. 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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4
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: 02/27/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/27/2025


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 02/27/2025 06:25 PM - It Cannot Be Edited


Created By: Audrey Jeung On 02/27/2025 at 06:04 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: MAXIM RESIDENTIAL HOME
FACILITY NUMBER: 415600885

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/27/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1503.2
General Provisions
Every facility licensed or certified pursuant to this chapter shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections.

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 carbon monoxide detector is not operating efficiently, as it emits regular chirping sounds, even after new batteries are installed. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/06/2025
Plan of Correction
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Carbon monoxide detector will be replaced and operate efficiently. Proof of correction to be sent to CCLD BY DUE DATE
Type B
Section Cited
CCR
85088(c)(2)
Fixtures, Furniture, Equipment, and Supplies
(c) The licensee shall ensure provision to each client of the following furniture, equipment and supplies necessary for personal care and maintenance of personal hygiene. (2) Bedroom furniture including, in addition to (c)(1) above, for each client, a chair, a night stand, and a lamp or lights necessary for reading.

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 reading lights are inoperable in rooms of clients #1 and #2, and ceiling light is broken in room of client #1.
This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/06/2025
Plan of Correction
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Reading lights in 2 rooms and ceiling light will be replaced or repaired. Proof of correction to 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.
SUPERVISOR'S NAME:April Cowan
LICENSING EVALUATOR NAME:Audrey Jeung
LICENSING EVALUATOR SIGNATURE:
DATE: 02/27/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/27/2025


LIC809 (FAS) - (06/04)
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