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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385600068
Report Date: 10/15/2024
Date Signed: 10/15/2024 11:34:19 AM

Document Has Been Signed on 10/15/2024 11:34 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:FRANCIS RESIDENTIAL CARE HOMEFACILITY NUMBER:
385600068
ADMINISTRATOR/
DIRECTOR:		ANDRADE, ELY O.FACILITY TYPE:
735
ADDRESS:45 FRANCISTELEPHONE:
(415) 469-0350
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94112
CAPACITY: 6CENSUS: 4DATE:
10/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:20 AM
MET WITH:Ely AndradeTIME VISIT/
INSPECTION COMPLETED:
11:45 AM
NARRATIVE
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On 10/10/2024, Licensing Program Analyst (LPA) Dominic Tabola and LPA Yi Sam Jian conducted an unannounced annual inspection. LPA met with staff member, Alpha Andrade and Administrator, Ely Andrade, joined shortly there-after. LPA explained the purpose of the visit.

The middle level had 3 bed rooms for residents, 1 bathrooms, living room, kitchen, and dinning room. The first level had garage, 1 bath room for staff, and staff room.

Backyard had the storage room and laundry room. All outdoor and indoor passageway were free and clear of obstruction. LPA observed porch had excessive amount of personal belongs and recyclable items in need of disposal, technical violation. No accessible bodies of water or fire safety hazards observed.

Kitchen was inspected, sufficient supply of food observed. Infection control practices reviewed. Medications, toxins and sharps stored appropriately and inaccessible to clients, a comfortable temperature was maintained, hot water temperature inspected to be compliant, furnishing and lighting was sufficient for comfort and safety.

Carbon monoxide detector and smoke detector system inspected and met the requirements. fire extinguisher checked and fully charged. Facility has a written emergency disaster plan. Licensee has at least one completed first aid kit located in the kitchen.

Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed. Upon file reviews, LPA found needs and services for all residents needed to be updated, LPA found that administrator does not have active administrator certificate, LPA found all staff's first aid CPR training were expired.

Deficiencies of the Residential Care Elderly California Code of Regulations, Title 22, Division 6 is observed and cited on a LIC 809D. Failure to correct the deficiencies may result in civil penalties. This report is reviewed and discussed with the Administrator; a copy is provided.
SUPERVISORS NAME: Andrea Medlin
LICENSING EVALUATOR NAME: Yi Sam Jian
LICENSING EVALUATOR SIGNATURE: DATE: 10/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/15/2024
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 4
Document Has Been Signed on 10/15/2024 11:34 AM - It Cannot Be Edited


Created By: Yi Sam Jian On 10/15/2024 at 11:07 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: FRANCIS RESIDENTIAL CARE HOME
FACILITY NUMBER: 385600068

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(a)(12)(B)1
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (12) For employees that are required to be fingerprinted pursuant to Section 80019: (B) Documentation of either a criminal record clearance or exemption as required by Section 80019(e). 1. For Certified Administrators, a copy of their current and valid Administrator Certification meets this requirement.

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 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/29/2024
Plan of Correction
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Administrator submits proof of Administrator certificate training or enrollment by POC due date. Administrator submits proof of administrator certification as received.
Type B
Section Cited
CCR
80075(f)
Health-Related Services
(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.

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 2 out of 2 staffs which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/29/2024
Plan of Correction
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Administrator submits proof of first aid training by POC 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:Andrea Medlin
LICENSING EVALUATOR NAME:Yi Sam Jian
LICENSING EVALUATOR SIGNATURE:
DATE: 10/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/15/2024


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 10/15/2024 11:34 AM - It Cannot Be Edited


Created By: Yi Sam Jian On 10/15/2024 at 11:07 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: FRANCIS RESIDENTIAL CARE HOME
FACILITY NUMBER: 385600068

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80068.3(a)
Modifications to Needs and Services Plan
(a) The licensee shall ensure that each client's written Needs and Services Plan is updated as often as necessary to assure its accuracy, but at least annually. These modifications shall be maintained in the client's file.

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 4 out of 4 residents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/29/2024
Plan of Correction
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Administrator submits updated signed and dated Needs and Services Plan for all residents by POC due date.
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:Andrea Medlin
LICENSING EVALUATOR NAME:Yi Sam Jian
LICENSING EVALUATOR SIGNATURE:
DATE: 10/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/15/2024


LIC809 (FAS) - (06/04)
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