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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 380540130
Report Date: 01/24/2023
Date Signed: 01/24/2023 11:47:02 AM


Document Has Been Signed on 01/24/2023 11:47 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. FRANCIS MANOR IFACILITY NUMBER:
380540130
ADMINISTRATOR:ELMORALY, AMALFACILITY TYPE:
740
ADDRESS:1450 PORTOLA DRIVETELEPHONE:
(415) 564-8794
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94127
CAPACITY:12CENSUS: 2DATE:
01/24/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:55 AM
MET WITH:Staff, Mohamed ElmoralyTIME COMPLETED:
12:00 PM
NARRATIVE
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On 1/24/2023, Licensing Program Analysts (LPAs) Murial Han conducted an unannounced case management visit to deliver the findings in reference to complaint # 14-AS-20220906170901. LPA met with staff, Mohamed Elmoraly and explained the purpose of the visit.

During the course of the investigation, LPA reviewed resident #1 (R1)'s file and LPA observed R1 did not have pre-admission appraisal and the administrator acknowledged that it was not completed for R1.

Based on LPA observations and interviews which were conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 & Chapter 8, are being cited on the attached LIC809D. Failure to correct the deficiencies may result in civil penalties. Appeal rights given.

This report is reviewed and discussed with staff.

A copy is provided.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:
DATE: 01/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/24/2023
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 2


Document Has Been Signed on 01/24/2023 11:47 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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. FRANCIS MANOR I
FACILITY NUMBER: 380540130

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/24/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/01/2023
Section Cited

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87457 Pre-Admission Appraisal - General(a)Prior to admission, the prospective resident and his/her responsible person, if any, shall be interviewed by the licensee or the employee responsible for facility admissions.
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The administrator/licensee should review this regulation and develop a plan to ensure compliance. The administrator/licensee will submit a copy of such plan to CCL by 2/1/2023
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This requirement is not met as evidence by: the facility did not complete a pre-admission appraisal for resident #1 (R1) which posed a potential health risks to resident 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 SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:
DATE: 01/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/24/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2