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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601083
Report Date: 06/17/2024
Date Signed: 06/17/2024 10:35:47 AM


Document Has Been Signed on 06/17/2024 10:35 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:JUDY'S CARE HOME FOR THE ELDERLYFACILITY NUMBER:
415601083
ADMINISTRATOR:ROIAS, MARIA EFACILITY TYPE:
740
ADDRESS:125 A 24TH AVENUETELEPHONE:
(650) 345-6753
CITY:SAN MATEOSTATE: CAZIP CODE:
94403
CAPACITY:6CENSUS: 5DATE:
06/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:32 AM
MET WITH:Marissa MilanesTIME COMPLETED:
11:00 AM
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On 6/17/24 LPA Grace Donato made an unannounced annual visit to the facility. LPA met with Care Staff Marissa Milanes. LPA explained the purpose of the visit.

LPA toured the facility inside and outside including all of resident rooms, common areas & kitchen. The indoor and outdoor passageways were free of obstruction. The residents have adequate amount of linens and all personal belongings are intact. While touring the facility it was observed that the room temperature
was at 72 deg F. Hot water was also tested in the bathrooms and the temperature was 106 deg F. Carbon monoxide and smoke detector are present in the facility. Client bathrooms were observed to be in good repair equipped with grab bars and non-skid mats. LPA checked the food supply and there is adequate amount of food, 2 days for perishables and & 7 days non-perishable.

Five resident records and two staff records were reviewed. Staff have criminal record and fingerprint clearances on file. Staff have current First Aid/CPR certifications on file. Resident records were reviewed and were observed to be complete. Medication review was done, and all medications are accounted for, and centrally stored medication records are updated.

LPA requested the following documents: LIC308, Certificate of Liability Insurance, Administrator Certificate.

No deficiencies are cited at this time. Report is reviewed and a copy is provided.
SUPERVISOR'S NAME: Andrea MedlinTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Grace DonatoTELEPHONE: (714) 293-8294
LICENSING EVALUATOR SIGNATURE:
DATE: 06/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/17/2024
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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