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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601025
Report Date: 08/29/2022
Date Signed: 08/29/2022 11:32:43 AM


Document Has Been Signed on 08/29/2022 11:32 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
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:
08/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Administrator/Licensee, Maria FreitasTIME COMPLETED:
11:45 AM
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On August 29, 2022, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced annual infection control inspection. Upon arrival, LPA observed the COVID-19 signage posted at the front entrance. LPA met with Caregiver, Rodel Pinote and Administrator/Licensee, Maria Freitas joined shortly thereafter. LPA explained the purpose of the visit. LPA was screened at entry point. Caregiver was able to provide LPA screening log documentation for visitors.

LPAs toured the facility and grounds. No accessible bodies of water or fire safety hazards observed. This is a single story home with 10 bedrooms with 10 half bathroom in each room, and 1 full bathroom. Facility also has one staff with a half bathroom. All bedrooms were observed to be private resident rooms. There was one vacant room observed at this time. Shared bathroom was observed to be equipped with paper towels, hand washing sign, and liquid soap. LPA advised caregiver to ensure shared bathroom has a trash can with a lid.

Infection control practices are reviewed: COVID signage throughout the facility, face coverings, 30-day PPE supply, entry procedures, daily monitoring records for staff, residents and visitor.

LPAs toured the living room and dining room and it was clear and odor-free. The living room was clear from any tripping hazards. A comfortable temperate at 73 degrees F was maintained. Lighting was sufficient for comfort. LPA observed the first aid kit and medications locked and stored appropriately and inaccessible to residents. Washer and dryer was observed to be in good working condition.

LPAs toured the kitchen and observed 2 day perishable and 7 day non-perishable. LPA observed sharps drawer to be unlocked. LPA advised caregiver to immediately store them away so it's not accessible to residents.

CONT. to 809C
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 08/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/29/2022
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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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
VISIT DATE: 08/29/2022
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During the visit, 4 residents were observed to be maintaining social distancing in the living room.

LPA requests the following forms to be sent to CCLD by 9/6/22:
  • LIC309 Administrative Organization
  • LIC308 Designation of Administrative Responsibility
  • LIC500 Personnel Report
  • Administrator Certificate
  • LIC610E Emergency Disaster Plan


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 Administrator/ Licensee, Maria Freitas and a copy is provided with appeals rights.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 08/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 08/29/2022 11:32 AM - 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: 08/29/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(1)

87705 Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations, LPA observed drawer with sharps to be unlocked and accesible to residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/30/2022
Plan of Correction
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Administrator moved knives into a locked cabinet in LPA's prescence.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 08/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/29/2022
LIC809 (FAS) - (06/04)
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