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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385600360
Report Date: 10/02/2023
Date Signed: 10/02/2023 05:08:52 PM


Document Has Been Signed on 10/02/2023 05:08 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: 84DATE:
10/02/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Helen SilvaTIME COMPLETED:
05:15 PM
NARRATIVE
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In response to Incident Report dated 8/2/23--submitted to CCLD on 8/8/23--regarding client #1, LPA Jeung met with business office manager. Physician's Report dated 6/2021 and Needs and Services Plan dated 2/2023 were submitted to CCLD and reviewed.

Deficiencies of the California Code of Regulations, Title 22, are cited on a following page.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:
DATE: 10/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/02/2023
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 2


Document Has Been Signed on 10/02/2023 05:08 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 MANOR
FACILITY NUMBER: 385600360

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/02/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/09/2023
Section Cited
CCR
87705(c)(4)

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CARE OF PERSONS WITH DEMENTIA
Licensees who accept and retain residents with dementia shall be responsible for ensuring there is an adequate number of direct care staff to support each resident’s physical, social, emotional, safety and health care needs as identified in his/her current
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Plan/proof of correction to be submitted to CCLD BY DUE DATE, to ensure that this or similar incident is not repeated.
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appraisal.
This requirement was not met, as staff did not adequately supervise client on 8/3/23 when he eloped from facility. Licensee failed to ensure client's safety, which posed a potential health, safety or personla rights risk to clients in care.
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Type B
10/09/2023
Section Cited
CCR87705(c)(5)(A)

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CARE OF PERSONS WITH DEMENTIA
Each resident with dementia shall have an annual medical assessment... and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs. When any medical assessment, appraisal, or
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Plan/proof of correction shall be developed and submitted to CCLD BY DUE DATE.
This shall include updated MD report and Needs and Services Plan.
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observation indicates that the resident’s dementia care needs have changed, corresponding changes shall be made in the care and supervision...
This requirement was not met, as MD report is over 2 years old & appraisal does not adequately address wandering behavior.
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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: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:
DATE: 10/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/02/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2