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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385600360
Report Date: 07/12/2022
Date Signed: 07/12/2022 04:38:49 PM


Document Has Been Signed on 07/12/2022 04:38 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
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: 74DATE:
07/12/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Administrator, Ana PachecoTIME COMPLETED:
04:50 PM
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On 7/12/2022, Licensing Program Analyst (LPA), Murial Han conducted an unannounced Health and Welfare check as the facility admitted 3 residents from a skilled nursing facility and is anticipating to admit additional residents from the same facility . LPA met with the administrator and explained the purpose of today's visit.

According to the administrator, to ensure residents are appropriate for admission, the facility requests and reviews medical records, and conducts an on-site/ in-person assessment prior to admission. The administrator also stated that the facility has agreed to take additional residents from the same facility pending final review of their medical records. Furthermore, the administrator stated that the facility has increased its staffing level to accommodate the additional residents.

During today's visit, LPA Han reviewed and collected these documents: Identification and Emergency Information, LIC 602 (Physician's Orders), Preplacement Appraisal Information, Service Plan, Medication List and Staffing Assignments/Work Schedule.

In addition, LPA interviewed the 3 residents and they appeared with bright affect, they stated that the facility is providing the care that they needed but they need time to adjust as this is a new environment for them.

LPA requested additional documents to be submitted by 7/15/2022:
- Direct Care Staff Training Records
- Updated LIC500

No deficiency today. This report is reviewed with the administrator. A copy is provided.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:
DATE: 07/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/12/2022
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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