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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 01:40:54 PM


Document Has Been Signed on 01/24/2023 01:40 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. 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:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Staff, Mohamed ElmoralyTIME COMPLETED:
12:30 PM
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On 1/24/2023, Licensing Program Analyst(LPA) Murial Han conducted an unannounced annual inspection. LPA observed COVID-19 signs posted by the entrance. LPA was greeted by staff, Mohamed Elmoraly. LPA explained the purpose of the visit and staff contacted the administrator informing of today's inspection.

LPA toured facility and grounds. 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. there are 2 female residents and both of them are residing in a private room. Facility has 5 rooms on the 1st floor and 4 rooms downstairs. PPE supply is observed and LPA recommended to do additional purchasing; environmental cleaning supply are adequate, bathrooms are equipped with liquid soap and paper towels, hand washing instruction is posted by the hand washing stations. Trash can in the kitchen observed with closed foot operated lid.

Facility observed to be cleaned, and tidy; a comfortable temperature is maintained, and lighting is sufficient.

Medications, toxins and sharps are stored appropriately and inaccessible to residents. Food supply was checked and observed to be sufficient. First-aid kit is inspected and complete. There are 2 residents, and 2 staff members present during the inspection.

During today's inspection, LPA Han requested for the following document to be submitted to the Regional Office by 1/28/2023:
- Updated Emergency Disaster Plan LIC610E
- LIC500 (personnel summary)
- A copy of administrator certification

No deficiency cited today; this report is reviewed and discussed with staff, Mohamed Elmoraly and 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)
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