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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385600360
Report Date: 12/11/2024
Date Signed: 12/11/2024 01:00:01 PM

Document Has Been Signed on 12/11/2024 01:00 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:VICTORIAN MANORFACILITY NUMBER:
385600360
ADMINISTRATOR/
DIRECTOR:		ANA PACHECOFACILITY TYPE:
740
ADDRESS:1444 MCALLISTER STREETTELEPHONE:
(415) 921-7550
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94115
CAPACITY: 124CENSUS: 94DATE:
12/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:32 AM
MET WITH:Bernadette Joseph, Licensee & Ana Pacheco, AdministratorTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
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On 12/11/2024, Licensing Program Analyst (LPA) Dominic Tobola conducted an unannounced annual inspection and was greeted by Licensee, Bernadette Joseph. Administrator, Ana Pacheco was contacted and arrived later in the visit. Facility provides care for 94 residents, none of which receiving hospice services and some of which with a diagnosis of dementia.

LPA continued with a tour of the facility with staff, facility found to be clean and at a comfortable temperature with all exits free from obstruction. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguishers located on each resident floor, kitchen and common spaces were found to be charged. Facility is equipped with smoke and carbon monoxide detectors and fire safety systems monitored and serviced by outside agencies. LPA tested multiple carbon monoxide detectors all of which were found to be in working order.

There was a sufficient supply of both perishable and nonperishable foods as required, with food stored in the kitchen, sufficient for residents in care. Food supply is replenished weekly and stored in proper conditions. Facility provides a wide variety of meal preferences and preparation while also ensuring proper dietary restrictions are followed. Cleaning supplies and other toxins are safely stored in locked closets throughout each floor, all of which were secured upon inspection. There was a supply of hygiene products and paper products available for residents. All resident’s bedrooms have lighting & appropriate furnishings and bedding items.

Residents that were out in the community during the inspection were observed interacting with staff and fellow residents in the common areas, participating in activities and exercise. LPA observed residents to have a positive relationship with staff and the Administrator. The facility encourages regular family visits with various common areas, private visitation room and a large patio space with shading for resident use. Continued onto LIC809-C
SUPERVISORS NAME: Andrea Medlin
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE: DATE: 12/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/11/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: VICTORIAN MANOR
FACILITY NUMBER: 385600360
VISIT DATE: 12/11/2024
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LPA conducted a sample file review for residents and found dementia diagnosis residents' (R1 & R2) medical assessments in need of updating. All other resident records were found to be in order. Technical Violation. Upon a spot check of staff files, LPA found that caregiver staff have all annual training completed, however not all staff have 1st aid training completed. In addition, CPR certified staff were not present until the following afternoon shift. LPA found that the facility has previously been in contact with outside training agency for 1st aid & CPR but pending confirmed training date. Administrator to provide LPA with confirmed training date and proof of certification once completed. Technical Violations issued. Lastly, A spot check of medications was conducted and found that all medication counts, records and protocols are in order.

Ana Pacheco's Administrator Certificate 7001634740 is currently active through 11/13/2025

LPA requested the following documents be sent to CCL by COB 12/31/2024:

LIC 308 Designated Facility Responsibility
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
Liability Insurance

No deficiencies cited during today's visit.
SUPERVISORS NAME: Andrea Medlin
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:

DATE: 12/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2024
LIC809 (FAS) - (06/04)
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