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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 419210063
Report Date: 07/05/2023
Date Signed: 07/05/2023 08:07:20 PM

Document Has Been Signed on 07/05/2023 08:07 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:MARTIN'S HOMEFACILITY NUMBER:
419210063
ADMINISTRATOR:GINA RAFAELFACILITY TYPE:
735
ADDRESS:3508 MARTIN DRIVETELEPHONE:
(650) 581-1836
CITY:SAN MATEOSTATE: CAZIP CODE:
94403
CAPACITY: 3CENSUS: 3DATE:
07/05/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:05 PM
MET WITH:Gina RafaelTIME COMPLETED:
01:50 PM
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LPA Grace Donato made an unannounced annual visit to the facility. LPA met with caregiver Grace Gaffud and administrator Gina Rafael followed after. LPA explained the purpose of the visit.

LPA toured the facility inside and outside including resident rooms, common areas, kitchen area and garage. The indoor and outdoor passageways were free of obstruction. LPA observed one resident in the living room area having lunch. A comfortable room temperature of 74 deg F is maintained and lighting is sufficient for comfort. Hot water was also tested in the bathrooms and the temperature was 120 deg F. The residents have adequate amount of linens and care items. All personal belongings are intact. Carbon monoxide monitor is working properly. All fire extinguishers have been checked and current. Resident bedrooms and bathroom were observed to be in good repair equipped with grab bars and non-skid floor. LPA checked the food supply and there is adequate amount of food, 2 days for perishables and & 7 days non-perishable. Emergency drills are logged and done every quarter. LPAs observed sharps, toxins and chemicals to be locked and inaccessible to residents.

LPA reviewed 3 resident records and 3 staff records. Resident records are updated, complete and signed. Staff records are complete, with training logs that have met the basic requirement. One resident record showed expired first aid training. Administrator will schedule resident to do training. Facility has a certified administrator on site with complete certification and training requirements.

PNI money is all accounted for and correct. Medication review was done, and all medications are accounted for, and centrally stored medication records are updated.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE: DATE: 07/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/05/2023
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: MARTIN'S HOME
FACILITY NUMBER: 419210063
VISIT DATE: 07/05/2023
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LPA interviewed 2 residents and 1 staff member.

LPA requested licensee to submit the following by 07/07/2023:

LIC 500 Personnel Report
Administrator Certificate

No deficiencies are cited at this time. A technical violation is given. Report is reviewed with Administrator and a copy is provided.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE:

DATE: 07/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2023
LIC809 (FAS) - (06/04)
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