385600076-2-26-2025-14-AS-DTOA-DE9RX8-20250226122420

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 385600076
Report Date: 02/26/2025
Date Signed: 02/26/2025 12:24:36 PM

Document Has Been Signed on 02/26/2025 12:24 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:	STELLA'S CARE HOME I		FACILITY NUMBER:	385600076
ADMINISTRATOR/ DIRECTOR:	MARGIE VALERIA		FACILITY TYPE:	740
ADDRESS:	616 39TH AVENUE		TELEPHONE:	(415) 752-8652
CITY:	SAN FRANCISCO	STATE: CA	ZIP CODE:	94121
CAPACITY: 12	TOTAL ENROLLED CHILDREN: 0	CENSUS:	DATE:	02/26/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:45 AM
MET WITH:	Margie Valeria, Administrator		TIME VISIT/ INSPECTION COMPLETED:	12:40 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 2/26/2025, Licensing Program Analyst (LPA) Tobola conducted an unannounced Annual Required – 1 yr. inspection for this facility and was greeted by Administrator, Margie Valeria. The facility currently provides care for 10 residents, 1 resident who is receiving hospice services and some of which with a diagnosis of dementia. 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 Extinguishers located throughout the facility were found to be charged. Smoke detectors and sprinkler systems were present in each common room and resident bedroom with last fire safety inspection conducted in March 2024 ensuring all fire safety systems are in place. There is a designated closet for cleaning supplies, however, LPA requested Administrator to change garage doorknob to a lockable system in case of any items stored in the garage that could pose safety risk. Technical Assistance provided. 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 have 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 with medication counts in order. Continued onto LIC809-C

Andrea Medlin	TELEPHONE: (650) 266-8811
Dominic Tobola	TELEPHONE: (650) 393-9128
	DATE: 02/26/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2025

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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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: STELLA'S CARE HOME I	FACILITY NUMBER: 385600076
	VISIT DATE: 02/26/2025

NARRATIVE

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LPA conducted a sample file review for residents and found that 2 residents' (R1,R2) pre-appraisal assessments were not conducted prior to admission. Both residents were recently admitted and Administrator agrees to complete assessment for resident care needs. Upon a sample review of 5 staff files LPA found that all caregiver staff have current 1st aid and CPR and training on file.

Administrator, Margie Valeria's Administrator Certificate 7015084740 is valid through 2/22/2026

LPA requested the following updated documents be sent to CCL by COB 3/12/2024:

LIC 308 Designated Facility Responsibility
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan

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.

SUPERVISOR'S NAME: Andrea Medlin	TELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (650) 393-9128
LICENSING EVALUATOR SIGNATURE:	DATE: 02/26/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2025

LIC809 (FAS) - (06/04)

Page: 2 of 4

Document Has Been Signed on 02/26/2025 12:24 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: STELLA'S CARE HOME I	FACILITY NUMBER: 385600076
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/26/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

CCR

87457(c)

Pre-Admission Appraisal

(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of their individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 2 resident pre-appraisals not completed prior to resident admission, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/10/2025
	Plan of Correction
1 2 3 4	Administrator agrees to submit completed pre-appraisal assessments for residents (R1 & R2) by POC due date 3/10/2025.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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 Medlin	TELEPHONE: (650) 266-8811
Dominic Tobola	TELEPHONE: (650) 393-9128
	DATE: 02/26/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2025

LIC809 (FAS) - (06/04)

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