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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601025
Report Date: 12/06/2022
Date Signed: 12/06/2022 12:23:10 PM


Document Has Been Signed on 12/06/2022 12:23 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
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066



FACILITY NAME:MARIA'S HOME FOR THE ELDERLYFACILITY NUMBER:
415601025
ADMINISTRATOR:FREITAS, MARIAFACILITY TYPE:
740
ADDRESS:2836 FLORES STREETTELEPHONE:
(650) 458-3265
CITY:SAN MATEOSTATE: CAZIP CODE:
94403
CAPACITY:12CENSUS: 9DATE:
12/06/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Administrator, Licensee, Maria FreitasTIME COMPLETED:
12:30 PM
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On December 6, 2022, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced case management visit in relation to complaint control #14-AS-20220822124606 . LPA met with Licensee/Administrator, Maria Freitas and explained the purpose of the visit.

During a complaint investigation; complaint control #14-AS-20220822124606, the Licensee indicated that when a resident passes away, the prescription medications that are not taken are given to the resident's responsible party and a document is signed indicating the family received the medication. In addition, it was indicated if the responsible party does not take the medications, the medications are disposed with the hospice agency or at the police station.

Deficiency of the Residential Care Elderly California Code of Regulations, Title 22, Division 6 is observed and cited on a LIC 809D. Failure to correct the deficiencies may result in civil penalties.

Report is reviewed with Licensee, Maria Freitas and a copy is provided with appeals rights.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 12/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/06/2022
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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Document Has Been Signed on 12/06/2022 12:23 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066


FACILITY NAME: MARIA'S HOME FOR THE ELDERLY
FACILITY NUMBER: 415601025

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/06/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/13/2022
Section Cited

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87465 Incidental Medical and Dental Care: (i) Prescription medications which are not taken with the resident upon termination of services, not returned to the issuing pharmacy, nor retained in the facility as ordered by the resident’s physician and documented in the resident’s record nor disposed of according to the hospice’s established procedures or which are otherwise to be disposed of shall be destroyed in the facility by the facility administrator and one other adult who is not a resident. Both shall sign a record, to be retained for at least three years, which lists the following:
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Violation of this regulation is not met as evidenced by: According to the Licensee, when a resident passes away, the medications that are not used are given to the responsible parties.
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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: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 12/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/06/2022
LIC809 (FAS) - (06/04)
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