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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 380503819
Report Date: 05/16/2023
Date Signed: 05/16/2023 12:16:48 PM


Document Has Been Signed on 05/16/2023 12:16 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: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: 31DATE:
05/16/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Sister Mary William and Sister Anna Marie ZacherTIME COMPLETED:
12:25 PM
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On 5/16/2023, Licensing Program Analyst, Murial Han (LPA) conducted an unannounced case management visit. LPA met with facility staff Sister Mary William, Sister Anna Marie Zacher and HR Director Steve Lewey.

The purpose of today's visit is to ensure an excluded staff is no longer employed at the facility.

According to HR Director, facility received the exclusion letter for this individual from CCL and confirmed that this individual has never worked at the facility.

LPA reviewed the current staff list.

No deficiency cited today; this report is reviewed and discussed with Sister Mary William.

A copy is provided.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:
DATE: 05/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/16/2023
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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