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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415201202
Report Date: 02/15/2024
Date Signed: 02/15/2024 01:04:41 PM


Document Has Been Signed on 02/15/2024 01:04 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:BRITANNIA PLACEFACILITY NUMBER:
415201202
ADMINISTRATOR:DELPHINE WILLIAMSFACILITY TYPE:
740
ADDRESS:1515 MADDUX DRIVETELEPHONE:
(650) 369-8383
CITY:REDWOOD CITYSTATE: CAZIP CODE:
94061
CAPACITY:6CENSUS: 5DATE:
02/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:25 AM
MET WITH:Administrator - Mark WilliamsTIME COMPLETED:
01:10 PM
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On 02/15/2024 Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced 1 year annual inspection visit. LPA met with administrator Mark Williams and explained the purpose of today's visit.

LPA toured the facility inside and outside. Emergency exit routes are free and clear of obstructions. The facility's ambient temperature is comfortable and warm. Water is tested in two bathrooms as being 110F. Residents have an adequate amount of linens and incontinence supplies, incidental supplies, as well as PPE as needed. Linens are stored in a resident bathroom located at the rear of the facility. One fire extinguisher is observed at the end of the hallway centralized to resident rooms and laundry nook. Extinguisher is observed as being inspected 11/27/2023. Carbon monoxide detectors and smoke detectors are present through out the facility. Resident bathrooms are observed to be in working order with clean shower curtains and non-skid surfacing and strips are in place. Some residents bring their own toiletries to the bathrooms and some are stored and provided by staff upon request. 7 day non-perishable food supply and 2 day fresh food supply is observed as in place. Kitchen is observed as operable and clean. Appliances are in good working order. Knives are stored and locked in hallway cabinet along with cleaning solutions.

Medications are stored and inaccessible in a locked medication cabinet in the kitchen. Medications are reviewed to be in place and accurately marked in bubble packs and medication bottles. Centrally stored medication log is observed as current. First aid kit is complete and stored in hallway closet. On site laundry is available and functioning per observations made in at the end of the hallway central to two resident rooms

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SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8865
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:
DATE: 02/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/15/2024
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: BRITANNIA PLACE
FACILITY NUMBER: 415201202
VISIT DATE: 02/15/2024
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Page 2 - LIC809C

3 staff records are reviewed. All staff has criminal record clearance and are associated with the facility. Based on record reviews, TB tests, training, CPR/First Aid cards, and personnel files are current. 2 client records are checked and both are complete and updated. Disaster drills are current and vary per month. Last conducted in 12/24/2023. According to administrator each drill is different and varies for each drill conducted. Administrator certificate is observed is observed as current expiring 05/19/2024. Facility does not handle resident money.


The following updated items are requested to be sent to the Department by 02/22/2024:

• LIC610D Emergency Disaster Plan
• LIC 308 Designation of Administrative Responsibility
• LIC 500 Personnel Report
• Updated administrator certificate
• LIC9020 Client Roster
• Certificate of Liability Insurance
• Proof of control of property
• Surety bond with expiration date

Report is reviewed with administrator. No citations issued.
SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8865
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:

DATE: 02/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2024
LIC809 (FAS) - (06/04)
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