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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600999
Report Date: 04/29/2022
Date Signed: 04/29/2022 03:16:06 PM


Document Has Been Signed on 04/29/2022 03:16 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
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066



FACILITY NAME:ROBERTA CARE HOMEFACILITY NUMBER:
415600999
ADMINISTRATOR:GHLICHLOO, FATOLLAHFACILITY TYPE:
740
ADDRESS:1647 ROBERTA DRIVETELEPHONE:
(650) 389-7603
CITY:SAN MATEOSTATE: CAZIP CODE:
94403
CAPACITY:4CENSUS: 4DATE:
04/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Johnny MacabascoTIME COMPLETED:
03:15 PM
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LPA Audrey Jeung toured facility and grounds, including fenced backyard and detached storage shed. There are 4 private client bedrooms, 2 common bathrooms, living/dining room area, and kitchen. There is a small office, but no staff room. Washer and dryer are located in garage, which is the central entry point.

There are 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 posted prominently. Medications, toxins and sharps are stored appropriately and inaccessible to clients, a comfortable temperature is maintained, and lighting is sufficient for comfort and safety. First-aid kit is inspected and complete. A Disaster and Mass Casualty Plan is posted and up to date. There are 4 residents present, and 3 staff. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed; first-aid training for staff is current. Fatollah Ghlichloo and Johnny Macabasco are certified RCFE administrators (x 6/2022 and 12/2022) that oversee facility operations.

The following licensing forms are requested to be submitted to CCLD by 5/6/22:

- LIC 309 Administrative Organization
- LIC 500 Personnel Report
- Proof of current liability insurance
- Proof of current surety bond



No deficiencies of the RCFE Regulations, California Code of Regulations, Title 22, Division 6, are observed. Facility is operating in substantial compliance.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:
DATE: 04/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/29/2022
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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