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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600974
Report Date: 06/21/2021
Date Signed: 06/21/2021 10:59:57 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:KIMOCHI SAN MATEOFACILITY NUMBER:
415600974
ADMINISTRATOR:CHAN, LINDA ISHIIFACILITY TYPE:
740
ADDRESS:453 N SAN MATEO DRIVETELEPHONE:
(650) 388-7130
CITY:SAN MATEOSTATE: CAZIP CODE:
94401
CAPACITY:14CENSUS: 13DATE:
06/21/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Linda Ishii-ChanTIME COMPLETED:
11:00 AM
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PA Audrey Jeung toured facility and grounds, consisting of 11 client bedrooms, 3 of which are shared--all with full private bathrooms. Staff are observed wearing face coverings. No accessible bodies of water or fire safety hazards observed. Infection control practices are reviewed: entry procedures, staff training and policies, resident monitoring, containment strategies, environmental preparation and cleaning. PPE supply is adequate and infection control signs are prominently posted. Medications, toxins and sharps are stored appropriately and inaccessible to clients, a comfortable temperature is maintained, and lighting is sufficient for comfort and safety. 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. An updated Disaster and Mass Casualty Plan is accessible to staff. There are 13 residents present, and 2 caregivers. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed. Linda Ishii-Chan is a certified RCFE administrator (x 3/22) that oversees facility operations.

The following updated forms/information are requested to be submitted to CCLD BY 6/28/21:

• LIC 309 Administrative Organization
• Proof of current Liability Insurance
• RCFE staff medication training requirements


No deficiencies of the RCFE California Code of Regulations, Title 22, Division 6, Chapter 8 are observed. Facility is operating in substantial compliance..
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2021
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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