<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600742
Report Date: 07/22/2021
Date Signed: 07/27/2021 01:09:10 PM

Document Has Been Signed on 07/27/2021 01:09 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
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:PATRICIA HOMEFACILITY NUMBER:
415600742
ADMINISTRATOR:NAVARRO, AURELIAFACILITY TYPE:
740
ADDRESS:988 PATRICIA AVENUETELEPHONE:
(650) 347-3870
CITY:SAN MATEOSTATE: CAZIP CODE:
94401
CAPACITY: 6CENSUS: 5DATE:
07/22/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Aurelia NavarroTIME COMPLETED:
12:00 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
LPA Audrey Jeung toured facility and grounds. No accessible bodies of water or fire safety hazards are observed. There are 3 shared bedrooms for residents and 2 bathrooms--one designated for residents. In addition, there are 2 staff rooms for 4 live-in staff. Infection control practices are reviewed: entry procedures, staff training and policies, resident monitoring, containment strategies, environmental preparation and cleaning. PPE supply is adequate and infection control signs are posted prominently. Medications, toxins and sharps are stored appropriately and inaccessible to clients, a comfortable temperature is maintained, and lighting is sufficient for comfort and safety. Soap and paper towels are present in bathrooms and kitchen sink. Toilet and bathing facilities are equipped with grab bars and nonskid flooring material. First-aid kit is inspected and complete. A Disaster and Mass Casualty Plan is posted. There are 5 residents present, and 3 staff. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed; first-aid training for staff is current. Aurelia Navarro is a certified RCFE administrator (x 9/21) that oversees facility operations.

Updated Personnel Report (LIC500) to be sent to CCLD by 7/29/21.



No deficiencies of the General Licensing Regulations, of the California Code of Regulations, Title 22, Division 6, are cited. Facility is operating in substantial compliance.
SUPERVISORS NAME: Julio Montes
LICENSING EVALUATOR NAME: Audrey Jeung
LICENSING EVALUATOR SIGNATURE: DATE: 07/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/22/2021
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 1