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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385600360
Report Date: 12/11/2023
Date Signed: 12/11/2023 04:40:12 PM


Document Has Been Signed on 12/11/2023 04:40 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:
12/11/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Ana PachecoTIME COMPLETED:
04:45 PM
NARRATIVE
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As a follow up to case management visit on 10/2/23, LPA Jeung met with administrator to discuss citations issued on that day, and subsequent communications with regional office staff regarding client #1, referenced on LIC811 of 10/2/23. Ms. Pacheco advised that deficiencies were appealed, and are pending with CCLD.

Based on Needs and Services Plan for client #1 dated 2/15/23--observed at facility on 10/2/23 as well as submitted to CCLD--Plan was not signed and acknowledged by client or his/her responsible party.
Deficiency of the California Code of Regulations, Title 22, is 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: 12/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/11/2023
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 12/11/2023 04:40 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: 12/11/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/18/2023
Section Cited
CCR
87467(a)(3)

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RESIDENT PARTICIPATION IN DECISIONMAKING
...the licensee shall arrange ... to prepare a written record of the care the resident will receive in the facility....review and revise the written record as specified, when there is a significant change in the resident's condition,
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Plan of correction to be submitted to CCLD BY DUE DATE, which shall acknowledge that signatures of clients or their responsible parties shall sign appraisals, needs and services and care plans.
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 or once every 12 months, whichever occurs first. This requirement was not met, based on review of Needs and Services Plan for client #1. Licensee failed to ensure that the written record was acknowledged and signed by resident or his representative, which posed a potential health, safety or personal rights risk to residents in care.
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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: 12/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/11/2023
LIC809 (FAS) - (06/04)
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