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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 380503546
Report Date: 12/04/2020
Date Signed: 08/01/2023 11:46:04 AM

Document Has Been Signed on 08/01/2023 11:46 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
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:VERNON MANORFACILITY NUMBER:
380503546
ADMINISTRATOR:SUMPTER, MARCIAFACILITY TYPE:
735
ADDRESS:425 VERNON STREETTELEPHONE:
(415) 584-4257
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94132
CAPACITY: 14CENSUS: 9DATE:
12/04/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Administrator, Marcia SumpterTIME COMPLETED:
02:15 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
On 12/4/2020, LPA conducted an unannounced Case Management Inspection in response to the Incident Report that the facility reported to the RO. Due to the Pandemic, LPA has conducted this inspection remotely.

LPA Han interviewed the Administrator, Marcia Sumpter regarding the incident and obtained detail information.

LPA Han obtained updates from the Administrator, Marcia Sumpter regarding R1's well-being.

LPA requested for the following reports:

1. Copy of the police report
2. R1's Physician's Report
3. R1's Service Plan/ Care Plan

The Administrator stated that the above reports will be provided to the RO by 12/7/2020.

LPA has reviewed this report with the Administrator, Marcia Sumpter and will provide this report to her for signature.
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE: DATE: 12/04/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/04/2020
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