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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 380540130
Report Date: 01/03/2025
Date Signed: 01/15/2025 10:52:36 AM

Document Has Been Signed on 01/15/2025 10:52 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:ST. FRANCIS MANOR IFACILITY NUMBER:
380540130
ADMINISTRATOR/
DIRECTOR:		ELMORALY, AMALFACILITY TYPE:
740
ADDRESS:1450 PORTOLA DRIVETELEPHONE:
(415) 564-8794
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94127
CAPACITY: 12TOTAL ENROLLED CHILDREN: 0CENSUS: 1DATE:
01/03/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:20 AM
MET WITH:Walaa Elmoraly, Assistant Administrator & Amal Elmoraly, LicenseeTIME VISIT/
INSPECTION COMPLETED:
11:25 AM
NARRATIVE
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On 1/3/2025, Licensing Program Analyst (LPA) Tobola conducted an unannounced Annual Required – 1 yr. inspection for this facility and was greeted by Assistant Administrator/Caregiver, Walaa Elmoraly and Licensee, Amal Emoraly. The facility currently provides care for 1 resident who was out of the community for work during the inspection.

LPA continued with a tour of the facility with staff, facility found to be clean and at a comfortable temperature with all exits free from obstruction. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher located near the kitchen was found to be charged. Smoke and carbon monoxide detectors found throughout the facility were also present. Carbon monoxide detector was tested and found to be in working order. LPA informed that staff conduct emergency drills but do not have documentation.

There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations, with food stored in the kitchen refrigerator found to have appropriate coverings, enough for residents in care. Cleaning supplies and other toxins are safely stored upon inspection. There was a supply of hygiene products and paper products available for residents. Resident's bedroom has lighting & appropriate furnishings and bedding items. Restrooms for resident use were equipped with non-slip mats, grab bars and kept in good condition. Upon spot review of medications, LPA found that the facility has documentation of resident prescriptions on file.

There is an outdoor patio with shade and large outdoor backyard space for resident use. The resident attends work full time and is regularly out of the facility. Staff were observed cleaning the resident's bedroom and restroom, which are completed on a daily basis during the resident's work hours. LPA conducted a file review for resident (R1) and found physician's report in need of physician signature. Upon a review of 3 staff files LPA found that all caregiver staff have current 1st aid and CPR certification on file. Lastly, Licensee, Amal Emoraly's Administrator Certificate 7034704740 is valid through 12/23/2025.

Deficiency cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties.
Andrea MedlinTELEPHONE: (650) 266-8811
Dominic TobolaTELEPHONE: (650) 393-9128
DATE: 01/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/03/2025
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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Document Has Been Signed on 01/15/2025 10:52 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
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: 01/03/2025
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Medical Assessment
(a) Prior to a person's acceptance as a resident, the licensee shall obtain documentation of a medical assessment, signed by a licensed medical professional acting within the scope of their practice and made within the last year, to be kept in the resident's record.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 1 out of 1 resident medical assesments. LPA found that resident medical assessment was completed but missing physician signature, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/03/2025
Plan of Correction
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Licensee agrees to updated resident (R1) medical assessment with physician's signature, and provide a copy to CCLD by POC date 1/17/2025.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Andrea MedlinTELEPHONE: (650) 266-8811
Dominic TobolaTELEPHONE: (650) 393-9128

DATE: 01/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/03/2025

LIC809 (FAS) - (06/04)
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