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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600999
Report Date: 11/12/2024
Date Signed: 11/13/2024 08:01:50 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 11/13/2024 08:01 AM - 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:ROBERTA CARE HOMEFACILITY NUMBER:
415600999
ADMINISTRATOR/
DIRECTOR:		JOHNNY MACABASCOFACILITY TYPE:
740
ADDRESS:1647 ROBERTA DRIVETELEPHONE:
(650) 389-7603
CITY:SAN MATEOSTATE: CAZIP CODE:
94403
CAPACITY: 4TOTAL ENROLLED CHILDREN: 0CENSUS: 4DATE:
11/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Administrator - Johnny MacabascoTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
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On 11/12/2024, Licensing program Analyst (LPA) Jaime Vado conducted an unannounced required - 1 year inspection. LPA met with Administrator Johnny Macabasco and explained the purpose of today’s visit. Currently there is one client present in the facility and 4 staff.

This is a single level facility with 4 bedrooms for clients. Facility is equipped with fire sprinklers through out the facility and in client rooms. The facility is licensed for age 60 and over and approved for 4 non-ambulatory clients. LPA Vado toured the facility both inside and outside. All outdoor and indoor passageway are free and clear of obstructions for emergency exit routes in case of fire or emergency. Facility's ambient temperature is comfortable for residents and LPA. No pools or bodies of water were observed during today's visit on the premises. LPA observed fresh food supplies and emergency one week of nonperishable and two (2) days of perishable foods as in place. Knives are locked in the kitchen drawer across from the sink. Toxic chemicals are stored in locked cabinets located in the garage. An outdoor shed is observed to house additional cleaning supplies and chemicals including additional PPE and incontinence supplies. Medications are locked in a medication cart located in a central hallway connecting to all client rooms. Each client room observed contained the required furniture as outlined in regulations . Facility has functioning smoke detectors within the facility as well as carbon monoxide detectors. LPA observed carbon monoxide detector in the central hallway where all client rooms are located. The facility is equipped with two full bathrooms which are in good working order. Water temperature is tested at 112F. Facility tests water daily twice a day and keeps a log posted on the refrigerator in the kitchen. Fire extinguishers are observed through out the facility. One is observed in the garage and the kitchen area of the facility. Both observed as charged and ready for use per the dial reading on the extinguishers and an inspection date of 05/13/2024.

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April CowanTELEPHONE: (650) 266-8865
Jaime VadoTELEPHONE: (559) 476-9353
DATE: 11/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/12/2024
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: ROBERTA CARE HOME
FACILITY NUMBER: 415600999
VISIT DATE: 11/12/2024
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LPA observed all resident rooms as clean, free of odors, and contained all the required furniture per regulatory recommendations. Resident bathrooms are observed as clean and in good worker order. Shower floors are equipped with non-skid mats or flooring. Garage area is observed as in good repair housing additional supplies and laundry area. Both washer and dryer are observed as in good working order. LPA inspected the medications and the P&I monies of all 4 clients in care at the facility. Based on review of all resident files, medications, and P&I monies all items are current and logged accurately. Disaster fire drill last conducted on 09/06/2024 per log reviewed. Facility administrator certificate is observed as current expiring 12/24/2024.

The following updated forms are requested to be submitted to CCLD by 11/19/2024:

• Copy of updated administrator certificates as there are more than one administrator
• Copy of facility's liability insurance
• LIC308 Designation of responsible staff person
• LIC400 Affidavit Regarding Client/Resident Cash Resources
• LIC610E Emergency Disaster Plan
• LIC500 Staff Schedule
• Copy of control of property or copy of lease
• Copy of updated surety bond


There are no citations issued during today's visit. Report is reviewed with the Administrator and a copy is provided on this day.
SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8865
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:

DATE: 11/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2024
LIC809 (FAS) - (06/04)
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