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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385600360
Report Date: 12/02/2021
Date Signed: 12/03/2021 08:58:33 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:VICTORIAN MANORFACILITY NUMBER:
385600360
ADMINISTRATOR:ANA PACHECOFACILITY TYPE:
740
ADDRESS:1444 MCALLISTER STREETTELEPHONE:
(415) 921-7550
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94115
CAPACITY:124CENSUS: 71DATE:
12/02/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Administrator, Ana PachecoTIME COMPLETED:
01:40 PM
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On 12/2/2021, Licensing Program Analyst(LPA) Murial Han conducted an unannounced annual inspection. LPA observed COVID-19 signs posted by the entrance. LPA was greeted by the Administrator, Ana Pacheco. 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, staff training and policies, resident and staff daily monitoring records (staff is being screened by the receptionist when they arrive and when they leave), containment strategies( the facility has reserved a private room with a private restroom and equipped with a PPE supply cart). PPE supply and the environmental cleaning supply are adequate, bathrooms are equipped with liquid soap, paper towels, hand washing instruction is posted by the hand washing stations and LPA recommended to replace some of the trash cans with the foot operated lids.

COVID-19 signs observed to be posted around the facility. LPA observed many residents wearing face masks. The tables in the dinning rooms are spaced out at least 6" apart from each other. The beds in the shared bedrooms are 6"feet apart. The tables in the staff lounge is apart and LPA observed COVID-19 signs are posted. There are hand sanitizer dispensers installed in front of each elevator and in the nursing stations. The high touched areas are being disinfected every hour including the public phone on both floors.

Medications, toxins and sharps are stored appropriately and inaccessible to resident, a comfortable temperature is maintained, lighting is sufficient for comfort.

During today's inspection, LPA Han requested for the following documents to be submitted to the Regional Office by 12/7/2021:
- Updated Administrator Certification
- LIC 308 (Designation of Administrative Responsibility)
- LIC 610E (Emergency Disaster Plan)
- LIC 500 (Personnel Report)

No deficiency cited today. This report is reviewed and discussed with the Administrator, Ana Pacheco A copy is provided.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:

DATE: 12/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2021
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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