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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601142
Report Date: 11/30/2023
Date Signed: 11/30/2023 05:21:55 PM

Document Has Been Signed on 11/30/2023 05:21 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:ADAMS PAUL INCFACILITY NUMBER:
415601142
ADMINISTRATOR:DIONSON, ROMMELFACILITY TYPE:
740
ADDRESS:1778 ADAMS STREETTELEPHONE:
(650) 522-8108
CITY:SAN MATEOSTATE: CAZIP CODE:
94403
CAPACITY: 6CENSUS: 6DATE:
11/30/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Rosemarie VeridianoTIME COMPLETED:
05:30 PM
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Applicant Adams Paul Inc., represented by CEO Rosemarie Veridiano, has applied for RCFE licensure for 6 non-ambulatory elderly persons. Fire clearance has been approved. Facility is currently operated as Adams ICF/DD-N, #220000471 (effective 6/19/23 to 6/18/24), licensed by the CA Dept. of Public Health.

LPA Jeung toured facility and grounds of this one level facility. Also present during this inspection are CDSS RNs Helen Shi and Paul Chua, who are present to observe residents and review their health conditions.

Infection control reviews were conducted upon entry. There are 5 client bedrooms--4 private and 1 shared--2 full bathrooms, living/dining area, kitchen and garage. Facility sketch accurately reflects floor plan. There is a rear wooden deck and side ramps, and a detached storage shed in backyard where paint and extra supplies are stored. There is an adequate supply of personal protective equipment (PPE), fresh and perishable food supplies,
Bedrooms are observed with required furniture. Medications are secured in medication cabinet in dining area as well as closet near front bathroom. Toxins and chemicals are stored in locked detached storage shed and locked storage room in garage. Food preparation and service items are present, as well as supply of bed and bath linens. Hot water temperature is tested at 107 degrees in shower room. Carbon monoxide detectors are present in 4 bedrooms as well as common areas. There are 2 fire extinguishers.
The following items are observed and must be addressed prior to licensure:

1. Emergency Disaster Plan (LIC610E) is incomplete. Phone number for ambulance service must be included. Utility shut off locations must be corrected. Location of 2 fire extinguishers will be added to page 3 of LIC610E. (CCR 87465 Incidental Medical and Dental Care)
2. Front bathroom is not equipped with toilet grab bars. (CCR 87303 Maintenance and Operation)
3. There is no posting area designated for information related to family councils. (HSC 1569.158)
Continued on page TWO
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Audrey Jeung
LICENSING EVALUATOR SIGNATURE: DATE: 11/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/30/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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: ADAMS PAUL INC
FACILITY NUMBER: 415601142
VISIT DATE: 11/30/2023
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4. Set of all keys for facility vehicles, facility exits, and cupboards, cabinets must be made and be available in the event of an emergency. (HSC 1569.695)
5. Half bed rails are used for 4 residents, but half rail must be positioned so it is at the head of the bed, not part way down. (CCR 87608 Postural Supports)

The above items must be completed prior to licensure. Applicant to notify LPA upon completion, and a follow up visit may be made.

Facility phone number is verified 650/522-8108

Component III RCFE orientation is provided to RCFE administrator Rommel Dionson and Rosemarie Veridiano.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Audrey Jeung
LICENSING EVALUATOR SIGNATURE:

DATE: 11/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2023
LIC809 (FAS) - (06/04)
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