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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385600136
Report Date: 02/29/2024
Date Signed: 02/29/2024 04:17:48 PM

Document Has Been Signed on 02/29/2024 04:17 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:MAE BEA ANDREWS BOARDING CAREFACILITY NUMBER:
385600136
ADMINISTRATOR:STRAIN, NICOLE D.FACILITY TYPE:
735
ADDRESS:1691 NEWCOMB AVETELEPHONE:
(415) 648-8300
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94124
CAPACITY: 6CENSUS: 6DATE:
02/29/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Administrator, Nicole StrainTIME COMPLETED:
01:45 PM
NARRATIVE
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On February 29, 2024, Licensing Program Analysts (LPA) Murial Han conducted an unannounced annual visit. LPA was greeted by staff member, Arrion Patterson and administrator, Nicole Strain. LPA explained the purpose of the visit.

This facility is licensed to retain and serve 6 ambulatory residents who are 18 to 59 only. Current census was 6. A brief interview with Facility Designated Administrator was conducted.

LPA reviewed 3 resident files and all of them contained admission agreement, medical assessment- LIC 602 (Physician Order), Appraisal Needs and Service Plan, and Resident Identification information, etc.

LPA reviewed 3 staff files and based on observation, Staff #1 (S1) and Staff #2 (S2) did not have staff training records, documentation for TB and Health Screening and Staff #3 (S3) did not have a file ready to review at this time.

A tour of the facility was conducted. Washer and dryer were identified. It was observed the chemicals underneath the sink was unlocked and accessible to residents in care. Two additional locked cabinets were identified which held resident files, medication, and cleaning supplies.

A tour of the back yard was conducted. Perimeter fence and gate were in good repair with no hazards present.

Medications are locked in the medication and inaccessible to residents in care. A comfortable temperature is maintained and lighting is sufficient for comfort.
2 days of perishables and 7 days of nonperishable foods were observed for the residents.
A tour of the downstairs storage was conducted. It was observed that additional food supply was housed in this area.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE: DATE: 02/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/29/2024
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
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: MAE BEA ANDREWS BOARDING CARE
FACILITY NUMBER: 385600136
VISIT DATE: 02/29/2024
NARRATIVE
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A tour of the bathroom was conducted. Hot water temperature was conducted to ensure it was within the required range of 105-120 degrees.

A tour of the resident bedrooms were conducted. Resident furniture and furnishings were in good repair and in compliance at this time.

A tour of the living room, dining room, and other areas intended for resident use was conducted.

Fire extinguishers located in the kitchen and main hallway were serviced on 08/08/2023.

Civil Penalty was assessed today for repeat violation of section 80066(a) that was cited during the annual visit on 9/23/2023.

Based on observation, deficiency is cited under California Code of Regulations, Title, 22 cited on the LIC 809D. Failure to correct the deficiencies may result in civil penalties.


This report is reviewed and discussed with administrator. A copy of this report and the appeal rights were provided.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:

DATE: 02/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/29/2024
LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 02/29/2024 04:17 PM - It Cannot Be Edited


Created By: Murial Han On 02/29/2024 at 12:37 PM
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: MAE BEA ANDREWS BOARDING CARE
FACILITY NUMBER: 385600136

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
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4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as chemicals were observed under the kitchen sink which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/01/2024
Plan of Correction
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2
3
4
The administrator will develop a plan to ensure all chemicals are locked and inaccessible to residents in care. The plan shall include when the staff training will be conducted. The administrator will provide a copy of the signed and dated plan of correction to CCL by 3/1/2024.
Type A
Section Cited
CCR
80066(a)
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:

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as S3's file was not ready for review which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/01/2024
Plan of Correction
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The administrator will develop a plan to ensure all staff files are completed for review. The administrator will submit a copy of the required documents of S3 to CCL by 3/1/2024. The administrator will provide a copy of the signed and dated plan of correction to CCL by 3/1/2024.
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 Smith
LICENSING EVALUATOR NAME:Murial Han
LICENSING EVALUATOR SIGNATURE:
DATE: 02/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/29/2024


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 02/29/2024 04:17 PM - It Cannot Be Edited


Created By: Murial Han On 02/29/2024 at 12:37 PM
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: MAE BEA ANDREWS BOARDING CARE
FACILITY NUMBER: 385600136

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80066(a)(10)
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: (10) A health screening as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as 3 out of 3 staff members did not have health screening records in their files which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/01/2024
Plan of Correction
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The administrator will develop a plan to ensure all staff have completed the health screening process and have proof in the personnel files upon completion. In the plan, the administrator will indicate the date that all 3 staff will be completing their health screening and will provide a copy of the health screening documentation to CCL upon completion. The administrator will provide a copy of the signed and dated plan of correction to CCL by 3/1/2024.
Type A
Section Cited
CCR
80066(a)(11)
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: (11) Tuberculosis test documents as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review the licensee did not comply with the section cited above as 3 out of 3 staff did not have TB test documents in their personnel files which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/01/2024
Plan of Correction
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The administrator will develop a plan to ensure all staff have completed the TB screening process and have proof in the personnel files upon completion. In the plan, the administrator will indicate the date that all 3 staff will be completing their TB screening and will provide a copy of the health screening documentation to CCL upon completion. The administrator will provide a copy of the signed and dated plan of correction to CCL by 3/1/2024.
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 Smith
LICENSING EVALUATOR NAME:Murial Han
LICENSING EVALUATOR SIGNATURE:
DATE: 02/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/29/2024


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 02/29/2024 04:17 PM - It Cannot Be Edited


Created By: Murial Han On 02/29/2024 at 12:37 PM
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: MAE BEA ANDREWS BOARDING CARE
FACILITY NUMBER: 385600136

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80065(f)
Personnel Requirements
(f) All personnel shall be given on-the-job training or shall have related experience which provides knowledge of and skill in the following areas, as appropriate to the job assigned and as evidenced by safe and effective job performance.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as 3 out of 3 did not have any documents to proof that on-the-job training was completed which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/01/2024
Plan of Correction
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The administrator will develop a plan to ensure all staff have completed the on-the-job training and have proof in the personnel files upon completion. In the plan, the administrator will indicate the date that all 3 staff will be completing their on-the-job and will provide a copy of documentation upon completion. The administrator will provide a copy of the signed and dated plan of correction to CCL by 3/1/2024.
Type A
Section Cited
CCR
80075(b)(1)(A)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (1) In adult CCFs, facility staff who receive training may assist clients with metered-dose inhalers, and dry powder inhalers if the following requirements are met: (A) In ARFs, facility staff must receive training from a licensed professional.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as 3 out of 3 staff did not have training records to proof that this has been completed which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/01/2024
Plan of Correction
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The administrator will develop a plan to ensure all staff have completed the on-the-job training and have proof in the personnel files upon completion. In the plan, the administrator will indicate the date that all 3 staff will be completing their on-the-job and will provide a copy of documentation upon completion. The administrator will provide a copy of the signed and dated plan of correction to CCL by 3/1/2024.
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 Smith
LICENSING EVALUATOR NAME:Murial Han
LICENSING EVALUATOR SIGNATURE:
DATE: 02/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/29/2024


LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 02/29/2024 04:17 PM - It Cannot Be Edited


Created By: Murial Han On 02/29/2024 at 12:37 PM
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: MAE BEA ANDREWS BOARDING CARE
FACILITY NUMBER: 385600136

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1565(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 individuals served by the facility is not required during a drill. While a facility may provide an opportunity for individuals served by the facility to participate in a drill, it shall not require that participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and, if applicable, the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as administrator was not able to provide any documentation to proof that drills were completed accordingly which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/01/2024
Plan of Correction
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The administrator will develop a plan to ensure drills are conducted accordingly and will provide a copy of the dated and signed plan to CCL 3/1/2024.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME:Cara Smith
LICENSING EVALUATOR NAME:Murial Han
LICENSING EVALUATOR SIGNATURE:
DATE: 02/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/29/2024


LIC809 (FAS) - (06/04)
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