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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 380540408
Report Date: 08/24/2022
Date Signed: 08/24/2022 06:10:11 PM


Document Has Been Signed on 08/24/2022 06:10 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:JANET'S RESIDENTIAL FACILITY FOR THE ELDERLYFACILITY NUMBER:
380540408
ADMINISTRATOR:SPIRES, JANETFACILITY TYPE:
740
ADDRESS:2970 25TH AVENUETELEPHONE:
(415) 759-8137
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94132
CAPACITY:8CENSUS: 5DATE:
08/24/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:01 PM
MET WITH:Administrator, Janet SpiresTIME COMPLETED:
03:10 PM
NARRATIVE
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On 8/24/2022, Licensing Program Analyst(LPA) Murial Han and Co-Worker Kevin Gaines conducted an unannounced annual inspection. LPA observed COVID-19 signs around the facility. LPA was greeted by the administrator, Janet Spires. LPA explained the purpose of the visit and LPA was screened at the front entrance.

LPA toured facility and grounds. No accessible bodies of water or fire safety hazards observed. Infection control practices are reviewed: entry procedures, resident and staff daily monitoring records reviewed and observed residents are completed on a daily basis and staff are completed but facility needs to be more consistent with the documentation. PPE supply and the environmental cleaning supply are adequate; bathrooms are equipped with soap and paper towels, and hand washing instruction is posted by the hand washing stations. Signs are posted through-out the facility. Trash cans are observed to have foot operated lids. All beds are at least 6" apart from each other. Facility has designated a staff member to care for residents who are in quarantine/isolation.

Medications, toxins and sharps are stored appropriately and inaccessible to clients, a comfortable temperature is maintained, lighting is sufficient for comfort and safety and food supply was checked and observed to be sufficient. First-aid kits are inspected and complete. There are 5 residents, 4 staff members, and the administrator present during the inspection.

During today's inspection, LPA requested for a copy of the current administrator certification, however, the administrator acknowledged that it was expired and will start the renewal process soon. Based on observation, and interview, this deficient is cited under California Code of Regulations, Title, 22 cited LIC 809D. Failure to correct the deficiencies may result in civil penalties.

This report is reviewed and discussed with the Administrator and a copy is provided.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:
DATE: 08/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/24/2022
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 08/24/2022 06:10 PM - 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: JANET'S RESIDENTIAL FACILITY FOR THE ELDERLY
FACILITY NUMBER: 380540408

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/24/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87405(a)


This requirement is not met as evidenced by: (a) All facilities shall have a qualified and currently certified administrator.
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above as the administrator's certification expired and has yet started the renewal process which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/31/2022
Plan of Correction
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The administrator has made arrangement for the administrator at St. Francis Manor to be the acting administrator while working on the administrator certification renewal process. The administrator will submit a certification renewal plan and completion date to CCL by 8/3/12022.
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.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:
DATE: 08/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/24/2022
LIC809 (FAS) - (06/04)
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