<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385600360
Report Date: 08/10/2022
Date Signed: 08/10/2022 04:34:21 PM


Document Has Been Signed on 08/10/2022 04:34 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:VICTORIAN MANORFACILITY NUMBER:
385600360
ADMINISTRATOR:ANA PACHECOFACILITY TYPE:
740
ADDRESS:1444 MCALLISTER STREETTELEPHONE:
(415) 921-7550
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94115
CAPACITY:124CENSUS: 75DATE:
08/10/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
03:50 PM
MET WITH:Administrator, Ana PachecoTIME COMPLETED:
04:45 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 8/10/2022. Licensing Program Analyst (LPA) Murial Han conducted an unannounced health and welfare check. LPA met with the administrator and explained the purpose of today's visit.

Today's visit is to follow-up on the health and welfare check that was conducted on 7/12/2022 concerning 3 residents who were admitted from a skilled nursing facility.

The administrator reported that since LPA's last visit, the facility has not admitted any additional residents from the skilled nursing facility. However, the facility is anticipating to take more and the facility will follow the pre-admission process prior to admitting new residents such as reviewing the medical records, conducting an on-site assessment, completing the pre-admission appraisal and the LIC602 (Physician's Report).

During today's visit, LPA met with the 3 residents and they stated that they are doing well.

No deficient cited today.

This report is reviewed and discussed with the administrator. A copy is provided.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:
DATE: 08/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/10/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1