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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600900
Report Date: 05/03/2024
Date Signed: 05/03/2024 03:02:50 PM


Document Has Been Signed on 05/03/2024 03:02 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:ABIGAIL COMPLETE CARE, INCFACILITY NUMBER:
415600900
ADMINISTRATOR:FRAGIACOMO, VIVIANFACILITY TYPE:
740
ADDRESS:1230 HOPKINS AVENUETELEPHONE:
(650) 224-8853
CITY:REDWOOD CITYSTATE: CAZIP CODE:
94062
CAPACITY:24CENSUS: 24DATE:
05/03/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Administrator - Vivian FragiacomoTIME COMPLETED:
03:00 PM
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On this day, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced required - 1 year inspection visit. LPA met with administrator Vivian Fragiacomo and explained purpose of today's inspection.

Prior to entry LPA was tested for COVID via rapid testing. LPA was screened appropriately prior to entry. PPE supply is observed as in place stored through out the facility via substations. There is also PPE stored in storage closets in main dining room area. Staff is observed wearing masks through out the facility. Mitigation and infection control plans are current and being followed.

This is a single level facility. Hospice waiver for 12 residents of which there are 7 residents under hospice care. There are no accessible bodies of water or fire safety hazards observed. Medications, toxins and sharps are stored appropriately and inaccessible to clients. Facility ambient temperature is warm and comfortable at 71F per facility thermostat, and lighting is sufficient for residents and staff safety. Toilet and bathing facilities are equipped with grab bars and non-skid mats. LPA observed one shower room adjacent to room 20. Shower rooms have pull cords present. Water temperature is tested in shower room at 120F. Liquid soap and paper towels are present in resident room bathrooms observed. LPA observed resident rooms 8 and 5 which have pull cords in place. Resident rooms observed contain all required furnishings and lighting. Facility has three first-aid kits that are in place through out the facility. A Disaster and Mass Casualty Plan is observed as posited. Additional food supplies are observed as in place in main kitchen and storage area. Two day perishable and one week non-perishable food supplies are observed as in place. Criminal record clearances or exemptions for facility staff or other individuals who have client contact are current. Fire extinguishers inspected are current with inspection tags dated 04/01/2024. Carbon monoxide detectors are observed as in place through out the facility. Facility is fully equipped with fire sprinklers.

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SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8865
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:
DATE: 05/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/03/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: ABIGAIL COMPLETE CARE, INC
FACILITY NUMBER: 415600900
VISIT DATE: 05/03/2024
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Page 2 - LIC809

Janitor closet is observed in the dining room area as locked and contains cleaning supplies and pre measuring equipment for use by cleaning staff. Laundry room is also observed adjacent to the kitchen area behind key pad locked door as functioning and clean. Facility is equipped with full fire sprinkler system. Fire alarm system, including the fire control panel, was last inspected on 03/06/2024 per records reviewed. Emergency disaster drills are conducted quarterly last taken place in January 2024 at 2pm. Emergency egress routes were followed and observed to be free and clear of obstructions.

Per file reviews made records observed as current. Administrator certificate is current and expiring November 2024. Facility does not handle resident monies.

The following updated forms are being requested to be received by 05/10/2024:

• LIC610D Emergency Disaster Plan
• LIC 308 Designation of Administrative Responsibility
• LIC 500 Personnel Report
• Updated administrator certificate
• LIC9020 Client Roster
• Certificate of Liability Insurance
• Control of Property

No citations issued. Report is reviewed the administrator Vivian Fragiacomo.
SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8865
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:

DATE: 05/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2024
LIC809 (FAS) - (06/04)
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