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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 380503546
Report Date: 11/14/2024
Date Signed: 11/14/2024 03:54:36 PM

Document Has Been Signed on 11/14/2024 03:54 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:VERNON MANORFACILITY NUMBER:
380503546
ADMINISTRATOR/
DIRECTOR:		SUMPTER, MARCIAFACILITY TYPE:
735
ADDRESS:425 VERNON STREETTELEPHONE:
(415) 584-4257
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94132
CAPACITY: 14CENSUS: 6DATE:
11/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:10 PM
MET WITH:Jasmine Hendrix, Lead CaregiverTIME VISIT/
INSPECTION COMPLETED:
04:10 PM
NARRATIVE
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On 11/14/2024, Licensing Program Analyst(LPA) Dominic Tobola conducted an unannounced annual inspection and was greeted by Lead Caregiver Staff, Jasmine Hendrix. Licensee, Marcia Sumpter was contacted and notified of the visit. Facility provides care for 6 clients all of which were present or returning from day program at the time of visit.

LPA continued with a tour of the facility with staff, facility found to be clean and at a comfortable temperature with all exits free from obstruction. Client’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguishers were found in the kitchen and upstairs hallway area were charged. LPA observed 1 fire extinguisher located near the downstairs hallway in need of service/charge. Smoke and carbon monoxide detectors were interconnected, found throughout the facility and in working order.

There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations, with food stored in the kitchen refrigerator found to have appropriate coverings, enough for clients in care. There was a supply of hygiene products and paper products available for clients. All client’s bedrooms have lighting & appropriate furnishings and bedding items.

5 of 6 clients attend day program Monday through Friday with transportation provided. The facility provides various outings in the community, parks and shopping centers. There is an outdoor patio that is equipped with shade with sufficient space for client use. There is also a sufficient amount of activity supplies located in the dining room.

A spot check of medications was conducted and found all records and medication count to be in order. Upon review of client records, LPA found that 3 out of 3 client appraisals are in need of updating. Technical Violation issued. In addition, 3 out of 3 clients physician's reports were not on file and in the process of updating. Technical Violation issued. Upon spot review of staff records, LPA found that 1 out of 2 staff require updated 1st aid & CPR certification. Technical Violation issued. Lastly, LPA found that Administrator, Marcia Sumpter does not have a current Administrator Certificate on file nor have they submitted training records to the Department. Citation issued. Appeal rights given.

LPA Requested for the following items to be submitted to CCLD by 11/28/2024:
LIC 308 Designated Facility Responsibility LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
SUPERVISORS NAME: Andrea Medlin
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE: DATE: 11/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/14/2024
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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Document Has Been Signed on 11/14/2024 03:54 PM - It Cannot Be Edited


Created By: Dominic Tobola On 11/14/2024 at 03:35 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: VERNON MANOR
FACILITY NUMBER: 380503546

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(a)(12)(B)1
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (12) For employees that are required to be fingerprinted pursuant to Section 80019: (B) Documentation of either a criminal record clearance or exemption as required by Section 80019(e). 1. For Certified Administrators, a copy of their current and valid Administrator Certification meets this requirement.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on review of records the licensee did not comply with the section cited above due to Administrator without a current Administrator Certification which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/28/2024
Plan of Correction
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Administrator agrees to submit proof of training or documentation for Administrator Re-Certification and receipt of delivery to the Department Administrator Certification Unit to CCLD by POC date 11/28/2024. In addition, Administrator to provide copy of Administrator Certificate once updated.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Andrea Medlin
LICENSING EVALUATOR NAME:Dominic Tobola
LICENSING EVALUATOR SIGNATURE:
DATE: 11/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/14/2024


LIC809 (FAS) - (06/04)
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