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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 380503819
Report Date: 11/03/2022
Date Signed: 11/04/2022 08:56:23 AM


Document Has Been Signed on 11/04/2022 08:56 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:ST. ANNE'S HOME FOR THE AGEDFACILITY NUMBER:
380503819
ADMINISTRATOR:SISTER ANNA MARIE ZACHERFACILITY TYPE:
740
ADDRESS:300 LAKE STREETTELEPHONE:
(415) 751-6510
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94118
CAPACITY:41CENSUS: 34DATE:
11/03/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Sister Mary WilliamTIME COMPLETED:
11:35 AM
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Licensing Program Analyst, Murial Han (LPA) conducted an unannounced annual inspection on 11/3/2022. LPA met with facility staff Sister Mary William.

LPA toured the facility, including 2 RCFE hallways, common area, chapel, auditorium, laundry room, kitchen, dining room, spa, kitchenette, and 3 bathrooms. All staff members observed to be wearing masks. No accessible bodies of water or fire safety hazards observed. Infection control practices are reviewed: entry procedures, staff training and policies, resident and staff daily monitoring records, containment strategies.

All emergency exits noted to be clear of obstruction. All rooms in facility noted to be cleaned and well maintained. Hand sanitizers, soap, and paper supplies were observed to be available.

Facility observed to have designated entry point. Staff took LPA's temperature and screened for symptoms. 30 day supply of PPE observed. All shared restrooms stocked with paper towels. Hand washing signs observed in all bathrooms. Social distancing signs observed to be posted in all public areas.

No deficiencies cited during today's visit. This report was reviewed with Sister Mary William and a copy of the signed report was provided.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:
DATE: 11/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/03/2022
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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