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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601061
Report Date: 09/09/2024
Date Signed: 09/09/2024 02:49:18 PM

Document Has Been Signed on 09/09/2024 02:49 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:GARDEN COURT AT THE VILLAGEFACILITY NUMBER:
415601061
ADMINISTRATOR/
DIRECTOR:		ALEXANDER, CARIDADFACILITY TYPE:
740
ADDRESS:137 POINSETTIA AVETELEPHONE:
(650) 269-3974
CITY:SAN MATEOSTATE: CAZIP CODE:
94403
CAPACITY: 6CENSUS: 6DATE:
09/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:45 PM
MET WITH:Administrator - Caridad AlexanderTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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On 08/27/2024, Licensing Program Analyst (LPA) Vado Jaime Vado conducted an unannounced annual required inspection visit. LPA met with administrator Caridad Alexander. There are currently 6 residents in the facility during today's visit and 4 staff present including the administrator.

This is a single level facility licensed for residents age range of 60 years and over all of which may be non-ambulatory. License is approved for 5 hospice residents. There is 1 hospice resident as of today's inspection visit. The physical plant was toured inside and outside of the facility to ensure the safety of the residents. There are no video cameras on site per the administrator. LPA observed the facility kitchen which is clean and observed appliances that are in good repair. Knives are stored and locked in a lower kitchen cabinet across from the stove. Perishable and non-perishable food items are observed as in place. There is an additional refrigerator and freezer in the garage area which carries additional food supplies for resident use. First aid kit is observed as complete with required items. Medications are observed to be locked in the kitchen in several kitchen cabinets. LPA observed at least two fire extinguishers in place which are currently within operating range, smoke detector, carbon monoxide detectors are observed in place through out the facility, and central heating. Facility is not equipped with fire sprinklers. PPE is observed to be in place stored in a closet within a resident bathroom. Laundry area is also observed as fully operational in the garage. Emergency exit routes are observed inside and outside to be free and clear of obstructions. Last emergency/disaster drill was conducted on 06/14/2024. Water temperature was measured at 110F. Cleaning supplies are observed to be locked in the kitchen, in the garage, and in a hallway closet in the main hallway.

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SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Jaime Vado
LICENSING EVALUATOR SIGNATURE: DATE: 09/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/09/2024
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: GARDEN COURT AT THE VILLAGE
FACILITY NUMBER: 415601061
VISIT DATE: 09/09/2024
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LPA observed all resident rooms as clean, free of odors, and contained all the required furniture per regulatory recommendations. Extra resident linen supplies are observed as in place in hallway closet and some in each resident's room. Resident bathrooms are observed as clean and in good worker order. Shower floors are equipped with non-skid mats or flooring. Facility does not handle resident monies. Medications and logs are observed today as current. During today's inspection LPA reviewed 3 resident files which are current and 3 staff files which are current. Administrator certificate is observed as expired on 08/2024 but according to the administrator she submitted the renewal items in July 2024 and is awaiting the updated certificate.

The following updated forms are requested to be submitted to CCLD by 09/16/2024:

• Copy of updated administrator certificate
• Copy of facility's liability insurance
• LIC308 Designation of responsible staff person
• LIC610E Emergency Disaster Plan
• LIC500 Staff Schedule
• Copy of control of property or copy of lease

No citations issued on this day. Report is reviewed with Caridad and a copy is provided on this day.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Jaime Vado
LICENSING EVALUATOR SIGNATURE:

DATE: 09/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2024
LIC809 (FAS) - (06/04)
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