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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385600360
Report Date: 01/27/2023
Date Signed: 01/31/2023 12:38:24 PM


Document Has Been Signed on 01/31/2023 12:38 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
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:
01/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Administrator, Ana PachecoTIME COMPLETED:
01:00 PM
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On 1/27/2023, 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.

There are 2 dining rooms on the 2nd and 3rd floor, 1 nursing station on each floor and medication room is located on the 2nd floor.

COVID-19 signs observed to be posted around the facility. The beds in the shared bedrooms are 6"feet apart. LPA observed COVID-19 signs are posted in the staff lounge. 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; first aide kit inspected and complete; a comfortable temperature is maintained, lighting is sufficient for comfort.

No deficiency cited today. This report is reviewed and discussed with the Administrator, Ana Pacheco. A copy is provided.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:
DATE: 01/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/27/2023
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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