385600385-6-11-2025-14-AS-DTOA-DHJNY2-20250611105201

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 385600385
Report Date: 06/11/2025
Date Signed: 06/11/2025 10:52:17 AM

Document Has Been Signed on 06/11/2025 10:52 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME:	CORINTHIAN GARDEN RESIDENTIAL CARE HOME		FACILITY NUMBER:	385600385
ADMINISTRATOR/ DIRECTOR:	ENCARNACION, WILLIAM S.		FACILITY TYPE:	740
ADDRESS:	170 APTOS AVENUE		TELEPHONE:	(415) 841-0311
CITY:	SAN FRANCISCO	STATE: CA	ZIP CODE:	94127
CAPACITY: 6		CENSUS: 5	DATE:	06/11/2025
TYPE OF VISIT:	Office	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:00 AM
MET WITH:	Licensee, William Encarnacion and Administrator, Anna Aoay		TIME VISIT/ INSPECTION COMPLETED:	11:00 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 6/11/25, Licensing Program Analysts (LPAs) Dominic Tobola, Yi Sam Jian and Licensing Program Manager (LPM) April Cowan met with Licensee, William Encarnacion and Administrator, Anna Aoay. During the meeting, LPM, Cowan and LPAs, Jian & Tobola went over and elaborated each item of the Stipulation and Waiver; And Order (“Stipulation”) that was effective on April 22, 2025. During the meeting, LPM elaborated on the stipulation order regarding the facility's license revocation, exclusion and administrator certificate revocation which have been stayed with probation from April 22, 2025 to April 22, 2028 pursuant to the following conditions: A. Respondent must strictly comply with all laws and regulations governing Residential Care Facilities for the Elderly (RCFEs). B. The Department may conduct unannounced inspections during probation to ensure full regulatory compliance. C. All individuals at the facility must have verified criminal clearances or exemptions before their presence and maintain proof on-site. D. Respondents must monitor everyone at the facility to ensure no one is under the influence of illicit drugs. E. Residents must be reappraised within seven days following any unusual incident or hospitalization. F. Staff must receive monthly Title 22 training, with attendance records kept and make-up sessions required within seven days unless otherwise approved. G. Unusual incidents must be reported to Licensing by the next working day with a written report submitted within seven days. Continued in 809-C

NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: Dominic Tobola
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/11/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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: CORINTHIAN GARDEN RESIDENTIAL CARE HOME	FACILITY NUMBER: 385600385
	VISIT DATE: 06/11/2025

NARRATIVE

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H. Medications and toxic substances must be safely stored in locked areas accessible only to authorized staff.
I. The facility must be maintained in a clean, safe, and sanitary condition at all times.
J. All administrators must complete specified training during the probationary period.
K. Current and prospective residents and their families must be informed of the probationary license and sign an acknowledgment kept in the resident’s file.
L. The Stipulation must be visibly posted at each facility throughout the probationary period.

The revocation of Licensee's administrator certificate shall also be stayed with probation from April 22, 2025 to April 22, 2028. Licensee shall be granted a probationary certificate pursuant to the following conditions:

A. Respondent may only serve as administrator for Respondent Corinthian and is prohibited from serving as administrator for Respondent Psalm.
B. Respondent must complete 40 hours of Department-approved training—25 hours in person—covering RCFE regulation, resident rights and care, behavior observation, facility safety, incident reporting, resident assessments, and medication handling.

LPM also went into further detail on the remaining sections of the stipulation including future application for a license registration certification or approval, tolling of probationary period, completion of probation, violation of stipulation term, Department's authority, monitoring fee, waiver of hearing rights, waiver of appeal/modification rights, waiver of claims, public record, signatures, counterparts, effective date, no oral modification, and representations.

All meeting participants indicated that they understood the stipulation order.

No deficiencies cites during this visit. This report was reviewed with Licensee, William Encarnacion and Administrator, Anna Aoay and a copy of this report was provided.

NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: Dominic Tobola
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/11/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2025

LIC809 (FAS) - (06/04)

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