415601083-7-28-2020-14-AS-AJEG-BRXPQS-20200728113136

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 415601083
Report Date: 06/04/2020
Date Signed: 07/28/2020 11:31:42 AM

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:	JUDY'S CARE HOME FOR THE ELDERLY		FACILITY NUMBER:	415601083
ADMINISTRATOR:	ROIAS, MARIA E		FACILITY TYPE:	740
ADDRESS:	125 A 24TH AVENUE		TELEPHONE:	(650) 274-7146
CITY:	SAN MATEO	STATE: CA	ZIP CODE:	94403
CAPACITY:	6	CENSUS: 6	DATE:	06/04/2020
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Marissa Milanes, Nilda, Maria Freitas, Maria Roias		TIME COMPLETED:	01:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Applicant Judy's Care Home LLC--represented by managing member/administrator Maria Roias--has submitted an application to accommodate SIX elderly non-ambulatory adults in a Residential Care Facility for the Elderly (RCFE). Fire clearance is approved for 6 Non-ambulatory elderly clients in 6 private bedrooms. Facility is currently operating as Maria's Home for the Aged #410508912. Via FaceTime tele-visit, LPA Jeung inspected building and grounds. This one-level home consists of 7 bedrooms on the ground floor--6 for clients and one for staff, all with private half bathrooms--one shower/bathroom, living/dining area and kitchen. Bedroom furnishings meet requirements of Title 22. Washer and dryer are located in attached two-car garage, which is not accessible to clients. Carbon monoxide detector is tested and operable. There are 2 porches and a level paved patio/driveway. Dishes, glasses, utensils and cookware are present, as well as an adequate supply of linens, toiletries and 2-day perishable and 7-day non-perishable food supply. First aid kit is complete. Hot water temperature is tested and observed to be 112 degrees. Medications are stored in locked medication cabinet in living/dining room and household toxins are stored in garage. Required information is posted: 1) PUB474, pertaining to resident councils; 2) text of Health and Safety Code 1569.269 AND CCR Title 22 Section 87468.1 and 87468.2 (Personal Rights form LIC613C); 3) CCLD Hotline information; 4) nondiscrimination notice, and; 5) facility's visiting policy. Component III orientation is conducted with administrator applicant, Maria Roias. Continued on following page.

SUPERVISOR'S NAME: Brenda Chan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Audrey Jeung	TELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:	DATE: 06/04/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2020

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
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: JUDY'S CARE HOME FOR THE ELDERLY	FACILITY NUMBER: 415601083
	VISIT DATE: 06/04/2020

NARRATIVE

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The following items must be addressed prior to licensure:

1. Emergency Disaster Plan (LIC610E) must be revised to clearly indicate utility shut-off locations. Add electricity breaker box in hallway to Electricity Shut-off location on page 3. Delete "left" in Shut-off locations for electricity, gas and water. Instead, use east, west, north or south. (Section 87212 Emergency Disaster Plan).
2. Room numbers do not correspond to facility sketch (Section 87208 Plan of Operation).
3. Add your evacuation assembly location to (page 5 of LIC610E) planned evacuation procedures. (Health and Safety Code 1569.695[a][1])
4. Add that you have a battery operated radio to (page 5) procedures to access information needed to check emergency routes to be used for evacuation and relocation during an emergency or disaster. (Health and Safety Code 1569.695[a][6])

Facility phone number is 650/345-6753.

Applicant to submit the above referenced revisions to LPA Jeung.

----------------------This report is emailed to Maria Roias for review and signature--------------------------

SUPERVISOR'S NAME: Brenda Chan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Audrey Jeung	TELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:	DATE: 06/04/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2020

LIC809 (FAS) - (06/04)

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