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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385600136
Report Date: 02/13/2025
Date Signed: 02/13/2025 01:06:41 PM

Document Has Been Signed on 02/13/2025 01:06 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:MAE BEA ANDREWS BOARDING CAREFACILITY NUMBER:
385600136
ADMINISTRATOR/
DIRECTOR:		STRAIN, NICOLE D.FACILITY TYPE:
735
ADDRESS:1691 NEWCOMB AVETELEPHONE:
(415) 648-8300
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94124
CAPACITY: 6CENSUS: 6DATE:
02/13/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:25 AM
MET WITH:Nicole Strain, Administrator/Licensee and TIME VISIT/
INSPECTION COMPLETED:
01:15 PM
NARRATIVE
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On 02/13/2025, Licensing Program Analyst (LPA) Yi Sam Jian and John Calandra conducted an unannounced annual inspection. LPAs met with Administrator, Nicole Strain and explained the purpose of the visit.

LPAs toured the physical plant. The facility has a garage, staff room, staff bathroom, living room, 3 bedrooms, 1 bathroom, and a kitchen. The backyard was fenced, secure, and in good condition. All indoor and outdoor passageways were clear of obstructions. No accessible bodies of water or fire safety hazards were observed.

The facility had the required 7 days of non-perishables and 2 days of perishables on site. No food was expired. Medications, toxins, and sharps were stored appropriately and kept inaccessible to clients. A comfortable temperature was maintained throughout the facility. Furnishings and lighting were adequate for comfort and safety.

The carbon monoxide detector and smoke detectors were observed to be in working order. The fire extinguisher was checked and is fully charged. The first-aid kit was inspected and observed to have all required items.

LPAs received the following documents at the facility:

- Current LIC 500

LPAs requested the following documents be sent to the Department by 2/27/2025:

-Admission Policies

-Plan of Operation

-Transportation Policy/Procedures

Deficiency was cited under the California Code of Regulations, Title 22. Failure to correct the deficiency by the due date may result in civil penalties.

An exit interview was conducted. The report was reviewed and discussed with the Administrator, and a copy of the report along with appeal rights were provided.

SUPERVISORS NAME: Andrea Medlin
LICENSING EVALUATOR NAME: Yi Sam Jian
LICENSING EVALUATOR SIGNATURE: DATE: 02/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/13/2025
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 02/13/2025 01:06 PM - It Cannot Be Edited


Created By: Yi Sam Jian On 02/13/2025 at 12:15 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: 02/13/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(a)(10)
80066(a) Personnel Records: 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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80066(a) (10) Personnel Records: Based on record review, the licensee did not comply with the section cited above. The licensee did not have a health screening report for S1 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/24/2025
Plan of Correction
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Licensee/Administrator will send health screening report to CCLD 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: 02/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/13/2025


LIC809 (FAS) - (06/04)
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