San Mateo Villa

Type of visit: Required - 1 Year

On 05/26/2026, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced required 1 year inspection. LPA met with caregiver Emely De La Cruz and explained the purpose of today's visit. Later during the visit the administrator Elizabeth Viducich arrived and met with LPA. Currently there are 5 residents in place and 2 staff present, one of which is the administrator. The facility is licensed for age range 60 and over. All may be bedridden. The facility has a hospice waiver in place for 4 residents. 2 residents are currently on hospice. This is a single level facility. The facility ambient temperature is comfortable. There are 6 resident rooms. All rooms contain a half bathroom. Water temperature is tested in the common hallway full bathroom measuring as 112F. Cleaning supplies are observed to be locked in a hallway closet. Facility knives are observed to be locked in the hallway closet as well. Kitchen food supplies are observed to be in place with 2 day fresh food supply and canned goods fulfilling the 7 day emergency food supply. Canned goods are stored in a large hallway closet. The garage has three additional refrigerators for resident food. Laundry area is observed in the garage as well and is fully operational. Emergency water is stored in the garage as well. A tour of the outside of the facility is conducted. Emergency routes are free and clear of any obstructions. Smoke detectors and carbon monoxide detectors are located through out the facility. The facility is also equipped with 1 fire alarm pull in the front of the facility next to the front door. Continued on next page... Page 2 LPA observed 2 fire extinguishers in the facility with inspection tags dated 04/21/2026. Facility conducts emergency drill quarterly. The last drill that was conducted is logged as December 2025. Linens are in place for resident use stored in a hallway closet.LPA observed all resident rooms and observed that they contain the required furniture and lighting as outlined in Title 22. Medications, first aid kit, and sharps are stored appropriately. Toilet and bathing facilities are equipped with grab bars and non-skid mats. Hygiene supplies are in place. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed as current. LPA reviewed 3 staff files and 5 resident files on this day which appear to be current based on review. Staff training records are observed to be in place. Training has not been conducted based on file reviews within the last year. Administrator certificate for Elizabeth Viducich is observed as current expiring 08/27/2026. Co administrator certificate expired on 02/22/2028. The following updated items are to be received by 05/13/2026: • Copy of facility's liability insurance • LIC308 Designation of responsible staff person Report is reviewed with Elizabeth Viducich and a copy of this report is provided on this day. Technical violations are given on this day on the attached LIC9102TV page.the state’s words, verbatim · CDSS document, May 6, 2026

Type of visit: Required - 1 Year

On 04/24/2025, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced required 1 year inspection. LPA met with caregiver Emely De La Cruz and explained the purpose of today's visit. Later during the visit the administrator Elizabeth Viducich arrived and met with LPA. Currently there are 5 residents in place and 3 staff, one of which is the administrator. The facility is licensed for age range 60 and over. All may be bedridden. The facility has a hospice waiver in place for 4 residents. 2 residents are currently on hospice. This is a single level facility. The facility ambient temperature is comfortable. There are 6 resident rooms. All rooms contain a half bathroom. Water temperature is tested in the common hallway full bathroom measuring as 114F. Cleaning supplies are observed to be locked in a hallway closet. Facility knives are observed to be locked in the hallway closet as well. Kitchen food supplies are observed to be in place with 2 day fresh food supply and canned goods fulfilling the 7 day emergency food supply. Canned goods are stored in a large hallway closet. The garage has three additional refrigerators for resident food. Laundry area is observed in the garage as well and is fully operational. Emergency water is stored in the garage as well. A tour of the outside of the facility is conducted. Emergency routes are free and clear of any obstructions. Smoke detectors and carbon monoxide detectors are located through out the facility. The facility is also equipped with 1 fire alarm pull in the front of the facility next to the front door. LPA observed 2 fire extinguishers in the facility with inspection tags dated 04/15/2025. Facility conducts emergency drill quarterly. The last drill that was conducted is logged as March 2025. Linens are in place for resident use stored in a hallway closet. Continued on next page... Page 2 LPA observed all resident rooms and observed that they contain the required furniture and lighting as outlined in Title 22. Medications, first aid kit, and sharps are stored appropriately. Toilet and bathing facilities are equipped with grab bars and non-skid mats. Hygiene supplies are in place. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed as current. LPA reviewed 3 staff files and 5 resident files on this day which appear to be current based on review. Staff training records are observed to be in place. Training has not been conducted based on file reviews within the last year. Administrator certificate for Elizabeth Viducich is observed as current expiring 08/27/2026. The following updated items are to be received by 05/01/2025: • Copy of updated administrator certificate • Copy of facility's liability insurance • LIC308 Designation of responsible staff person • LIC610E Emergency Disaster Plan • LIC500 Staff Schedule • Copy of control of property or copy of lease Report is reviewed with Elizabeth Viducich. A copy of this report is provided to the facility.the state’s words, verbatim · CDSS document, Apr 24, 2025

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.625(b)(2) · Plan of correction due date: May 1, 2025

(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. This regulation has not been met as evidenced by: Based on file review conducted, caregiving staff #1 and #3 have not had annual training within the last year. Last staff training on file is documented in 2016 and 2017. There is no evidence that direct care staff received required annual dementia training . This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 24, 2025

Plan of correction: Proof that staff received required 8 hours of dementia training to be sent to CCLD BY DUE DATE

From the deficiency page — Deficiency type: Type B · Section cited: HSC1569.696(a) · Plan of correction due date: May 1, 2025

(a) All residential care facilities for the elderly shall provide training to direct care staff on postural supports, restricted conditions or health services, and hospice care as a component of the training requirements specified in Section 1569.625. The training shall include all of the following: Based on file review conducted, caregiving staff #1 and #3 have not had annual training within the last year. Last staff training on file is documented in 2016 and 2017. There is no evidence that staff have received annual 4 hours of training on hospice care, postural supports, restricted health conditions. Staff does not have proof of postural supports and restricted health conditions training. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 24, 2025

Plan of correction: Proof that staff received required 4 hours of training on hospice care, postural supports and restricted health conditions will be sent to CCLD BY DUE DATE.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(a) · Plan of correction due date: May 1, 2025

87506(a) Resident Records. A separate, complete, and current record shall be maintained for each resident in the facility, readily available to facility staff and to licensing agency staff and shall contained specified information. This regulation has not been met as evidenced by: Based on resident files reviewed, resident #1 does not have current physicians reports. Resident's reports are over 1 year old with no updated assessments or reports on file. This poses a potential health and safety risk for residents in care.the state’s words, verbatim · CDSS document, Apr 24, 2025

Plan of correction: Facility shall ensure that all residents with dementia have either a current physicians report or other assessment showing the resident has no change from last physician's report.

Type of visit: Required - 1 Year

On 5/7/24, Licensing Program Analyst (LPA) Grace Donato conducted an unannounced annual required inspection. LPA met with Lead Staff, Emely De La Cruz and explained the purpose of the visit. LPA toured the indoor and outdoor premises of the facility. The indoor and outdoor passageways were free of obstruction. LPA observed the resident shower room, and it is equipped with non-skid mats and grab bars. Bathroom is sanitary and odorless. The hot water temperature was measured in residents bathroom at 115 degrees Fahrenheit. The facility is observed to be clean, odorless, and well maintained. Residents bedrooms were observed to be well organized and fully furnished with adequate lighting. Sharps locked in kitchen inaccessible to residents. Toxic materials were observed locked in the garage and inaccessible to residents. Food supply in kitchen and garage freezer was observed with an adequate two day perishable and seven day non-perishable food supply. Carbon monoxide, smoke detectors, and fire extinguisher were present at the facility. Centrally stored medication was locked in the medication cabinet. All medication was labeled and sorted by resident name. Six resident records and three 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. LPA requested the facility to submit the following: Liability Insurance & LIC500. No deficiencies cited today. Report is reviewed and copy is provided.the state’s words, verbatim · CDSS document, May 7, 2024

Type of visit: Annual/Random

On 12/2/2023, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to conduct an annual visit. LPA met with staff member, Emiley De La Cruz and explained the purpose of the visit. LPA asked that SM De La Cruz called the Facility Designated Administrator to inform them the CCL was present at this time. There were two other staff members present at the time of this this visit, Nicole Dasig and Felina Mallazab. This facility is licensed to serve and retain 6 elderly residents, all of which may be bedridden. This facility also has a dementia plan on file and hospice waiver for 4 residents. Current census was 5. It was learned that the facility has 1 resident on hospice at this time. LPA reviewed 5 resident files and 4 staff files. The administrator has an active administrator certificate #6019095740 and expires on 08/27/2024. A tour of the facility was conducted. The interior of the physical plant was in good condition and sanitary. Fire extinguishers appeared to have been annually inspected by Reliable Fire Extinguisher Company on 04/13/2023. The kitchen area was toured. LPAs observed a non-perishable and perishable foods in the cabinets and refrigerator. Additional perishable food supplies were identified in the garage. LPA observed a locked centralized stored medication cabinet located in the kitchen. Along with the administrator, the LPA observed, reviewed, and compared resident medication and medication dispensing logs. First Aid Kit was present and contained all of the required components. A tour of the bathrooms was conducted. Hot water temperature was measured and observed to be within the required range of 105-120 degrees. A linen closet was located in the hallway and presented a sufficient amount of linens to adequately supply and meet the needs of the residents at this time. A tour of the bedrooms was conducted. Resident furniture was observed to be sufficient to meet their needs at this time. Laundry area was toured. Laundry detergent, bleach, and all other cleaning supplies were observed to be locked and made inaccessible to the residents at this time. Common areas were toured. Living room, dining area and all other areas intended for resident use were observed to be furnished and maintained in compliance at this time. A tour of the garage was conducted. Additional perishable food supplies were identified. The exterior of the physical plant was toured. Perimeter fence was observed to be stable and gates were in good repair. The following forms and documents were requested to be updated and submitted into CCL -LIC 308 -LIC 400 -LIC 500 -LIC 610 A technical violation is being provided for Section 87355(e)(2) and a technical advisory is being provided for Section 87457(a) and 87465(h)(5) As a result of this visit, no deficiencies were observed or cited during this annual visit. An exit interview was conducted and copy of the 809 and 809-C was provided to facility at the end of this visit.the state’s words, verbatim · CDSS document, Dec 2, 2023