<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 380540130
Report Date: 02/20/2024
Date Signed: 02/20/2024 04:26:33 PM


Document Has Been Signed on 02/20/2024 04:26 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
SAN BRUNO RO, 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: 4DATE:
02/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:28 PM
MET WITH:Walla Elmoraly, CaretakerTIME COMPLETED:
04:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On February 20, 2024, Licensing Program Analyst(LPA) John Calandra arrived at the facility at 1:30 PM to conduct the Annual 1-year required Annual Inspection. LPA Calandra was greeted by Walla Elmoraly, Assistant Administrator/Caretaker and explained the purpose of his visit.

LPA Calandra toured the physical plant. This is a two story building that consists of 7 bedrooms and 3 bathrooms. Water in all bathrooms was measured between the required 105-120 degrees Fahrenheit. Bathrooms were observed to have the required grab bars and anti-skid mats. Fire extinguishers in the facility were observed to be fully charged and last inspected on June 7, 2023. The facility had the required 7 days of non-perishables and 2 days of perishables on site. No food was expired. The kitchen refrigerators and freezers temperature were within the required range. All bedrooms were sufficiently lit and had the required furniture. The backyard was clear from obstructions. No accessible bodies of water or hazards were observed. The facility does not handle any cash resources. The facility was maintained at a comfortable temperature of 70 degrees Fahrenheit.

All knives, sharp objects, soaps, detergents, and medications were observed to be locked and in-accessible to persons in care.

LPA Calandra reviewed 1 resident file and 2 staff files. The staff files were observed to be complete. The resident file was missing the Annual Needs and Services Plan.

Technical violations were provided for not having a facility sketch showing evacuation procedures, an appraisal of resident needs and services plans for each resident, and for not ensuring that at least one staff member who has CPR training is on duty at all times.

The facility received two Type A citations for failing to have Carbon Monoxide detectors and failing to conduct emergency drills at least quarterly.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: John CalandraTELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 02/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/20/2024
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 3


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: ST. FRANCIS MANOR I
FACILITY NUMBER: 380540130
VISIT DATE: 02/20/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
The following documents were requested to be sent to the department via Fax or email:

- Annual Needs and Services Plans for all residents
-Updated Facility Sketch with Evacuation Procedures
-Emergency disaster plan
-Administrator Certificate
-LIC 309-Administrative Organization
-Liability Insurance
-Updated LIC 500-Personnel Summary Report
-Updated CPR Training

Deficiencies of the California Code of Regulations, Title 22 are cited on the LIC 809-D. Failure to correct the deficiencies may result in civil penalties.

This report was reviewed with Walla Elmoraly, Assistant Administrator/Caretaker, and a copy along with appeal rights left at the facility.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: John CalandraTELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 02/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 03/06/2024 03:46 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 03/05/2024 04:35 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 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: 02/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.311
Regulations
Every residential care facility for the elderly shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
HSC 1569.311: Carbon Monoxide Detectors Required;
Based on observation and interview], the licensee did not comply with the section cited above in 1 out of 1 Carbon Monoxide Detectors which were not present in the facility. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/08/2024
Plan of Correction
1
2
3
4
Licensee/Administrator to submit proof of correction and a written plan outlining how this violation will be avoided in the future to licensing office by due date.
Type A
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
*This is an Amended Report*
HSC 1569.695(c) Emergency Plans: Based on interview with caretaker/Assistant Administrator, the licensee did not comply with the section cited above in 1 out of 1 emergency plans, in which staff did not have documentation, nor could recall the last time they had conducted an emergency disaster drill, which poses/posed a risk to resident's health and safety.
POC Due Date: 03/08/2024
Plan of Correction
1
2
3
4
Licensee/Administrator to submit proof of correction and a written plan outlining how this violation will be avoided in the future to licensing office by due date.
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: John CalandraTELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 02/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/20/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3