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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 380503546
Report Date: 12/08/2022
Date Signed: 12/08/2022 12:35:10 PM

Document Has Been Signed on 12/08/2022 12:35 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: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:
12/08/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Staff, Jasmine HendrixTIME COMPLETED:
12:45 PM
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On 12/8/2022, Licensing Program Analyst (LPA) Murial Han conducted a case management deficiencies visit. LPA met with staff, Jasmine Hendrix and explained the purpose of the visit. LPA was screened for COVID-19 by the entrance.

During the annual inspection on 11/8/2022, LPA observed administrator certification expired and requested a copy of the renewed certification to be submitted to Community Care Licensing (CCL) by 11/10/2022.

On 11/16/2022, CCL has not received a copy of the renewed administrator certification, therefore, LPA Han reached out to the administrator who acknowledged that the certification has been expired in 2019 and is currently seeking for an acting certified administrator for the facility while the administrator is working on the renewal process.

On 11/28/2022, the administrator stated that the candidate for the acting administrator has declined the offer.

Deficiency cited today under California Code of Regulations, Title 22, Division 6, Chapter 8 follows on LIC 809D as the facility does not have a qualified administrator. If cited deficiency is not corrected by the due date, a civil penalty may be assessed.

This report is discussed and reviewed with staff, Jasmine Hendrix.

A copy of this report and appeal rights were provided.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE: DATE: 12/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/08/2022
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 12/08/2022 12:35 PM - It Cannot Be Edited


Created By: Murial Han On 12/08/2022 at 12:09 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: 12/08/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/16/2022
Section Cited
CCR
85064(b)

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85064 Administrator Qualifications and Duties..(b) All adult residential facilities shall have a certified administrator.
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The administrator and/or licensee will send proof that the administrator re-certification is in the process of being renewed by the plan of correction due date 12/16/2022.
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This requirement is not met as evidenced by the administrator certification expired in 2019 which poses a potential health and risks to residents in care.
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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:Cara Smith
LICENSING EVALUATOR NAME:Murial Han
LICENSING EVALUATOR SIGNATURE:
DATE: 12/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/08/2022


LIC809 (FAS) - (06/04)
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