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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385600385
Report Date: 06/14/2023
Date Signed: 06/14/2023 10:29:14 AM


Document Has Been Signed on 06/14/2023 10:29 AM - 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:CORINTHIAN GARDEN RESIDENTIAL CARE HOMEFACILITY NUMBER:
385600385
ADMINISTRATOR:ENCARNACION, WILLIAM S.FACILITY TYPE:
740
ADDRESS:170 APTOS AVENUETELEPHONE:
(415) 841-0311
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94127
CAPACITY:6CENSUS: 5DATE:
06/14/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Caregiver, Juanita Salvievo TIME COMPLETED:
10:40 AM
NARRATIVE
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On June 14, 2023, Licensing Program Analysts (LPAs) Komal Charitra and Murial Han conducted an unannounced case management visit to deliver copies of amended reports that were provided on June 2, 2023, and issue additional deficiencies that were observed during the visit. LPAs met with Caregiver, Juanita Salviejo and explained the purpose of the visit.

During the visit, LPAs provided Caregiver, Juanita Salvievo a copy of the amended 809 and 809D to note Type B violation to a Type A violation for the following deficiency: 87307(a)(2)(B) Personal Accommodations and Services.

In addition, additional deficiencies are cited on 809D based on observations made on visit conducted on June 2, 2023.

Deficiency of the Residential Care Elderly California Code of Regulations, Title 22, Division 6 is observed and cited on a LIC809D. Failure to correct the deficiencies may result in civil penalties.

Report is reviewed with Caregiver and a copy is provided with appeal rights.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 06/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/14/2023
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 06/14/2023 10:29 AM - 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: CORINTHIAN GARDEN RESIDENTIAL CARE HOME
FACILITY NUMBER: 385600385

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/14/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/15/2023
Section Cited
CCR
87305(a)

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87305 Alterations to Existing Building or New Facilities: (a) Prior to construction or alterations, all facilities shall obtain a building permit.

Violation of this regulation is evidenced by:
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Licensee/Administrator to submit a written plan in writing addressing how to comply with CCR 87305(a).
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Based on observations, the Licensee altered the facility garage by building a bed and adding wooden walls for staff bedroom privacy without a proper building permit.
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Type A
06/15/2023
Section Cited
CCR87203

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87203 Fire Safety: All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.

Violation of this regulation is not met as evidenced by:
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Licensee/Administrator to submit a written plan in writing addressing how to ensure compliance with CCR 87203.
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Based on observations and record review, the Licensee failed to obtain a new fire clearance for the staff utilizing the garage as a sleeping area prior to having staff sleep in the garage which poses an immediate health and safety risk.
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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: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 06/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/14/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2