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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415201202
Report Date: 09/27/2024
Date Signed: 09/27/2024 09:38:05 AM

Document Has Been Signed on 09/27/2024 09:38 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:BRITANNIA PLACEFACILITY NUMBER:
415201202
ADMINISTRATOR/
DIRECTOR:		DELPHINE WILLIAMSFACILITY TYPE:
740
ADDRESS:1515 MADDUX DRIVETELEPHONE:
(650) 369-8383
CITY:REDWOOD CITYSTATE: CAZIP CODE:
94061
CAPACITY: 6CENSUS: 4DATE:
09/27/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:Dionisio Rigor, Caregiver TIME VISIT/
INSPECTION COMPLETED:
09:45 AM
NARRATIVE
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On September 27, 2024, Licensing Program Analyst (LPA) John Calandra arrived at the facility to conduct an unannounced Case Management visit to follow up on an incident report sent by the facility to the department on September 5, 2024, in which R1 left the facility unassisted. LPA Calandra was greeted by Dionisio Rigor, Caretaker and explained the purpose of the visit. Delphine Williams, Administrator/Licensee and Mark Williams, Administrator arrived later during the visit.

Based upon review of R1’s records, LPA Calandra found that R1 has a primary diagnosis of Alzheimer’s and is not cleared to leave the facility unassisted by the physician. Thus, R1 should not have been able to wander away from the facility. LPA and Administrator discussed several items including staff training plans, and other preventative measures in order to prevent further incidents of wandering from occurring.

A Type A violation was provided for not ensuring the facility’s plan of operations addresses safety measures to address behaviors such as wandering and aggressive behaviors.

The deficiencies are cited under the California Code of Regulations, Title 22. Failure to correct the deficiencies by the due date may result in civil penalties.

An exit interview was conducted. This report was reviewed with Delphine Williams, Administrator/Licensee and Mark Williams, Administrator, and a copy of the report along with Appeal Rights left at the facility.

SUPERVISORS NAME: Andrea Medlin
LICENSING EVALUATOR NAME: John Calandra
LICENSING EVALUATOR SIGNATURE: DATE: 09/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/27/2024
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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Document Has Been Signed on 09/27/2024 09:38 AM - It Cannot Be Edited


Created By: John Calandra On 09/27/2024 at 08:58 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: BRITANNIA PLACE
FACILITY NUMBER: 415201202

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/27/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
09/28/2024
Section Cited
CCR
87705(b)(2)

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(b) In addition to the requirements as specified in Section 87208, Plan of Operation, the plan of operation shall address the needs of residents with dementia, including: (1)Procedures for notifying the resident’s physician, family members and responsible persons who have requested notification, and conservator, if any, when a resident’s behavior or condition changes. (2) Safety measures to address behaviors such as wandering, aggressive behavior and ingestion of toxic materials.
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Administrator/Licensee to submit proof of correction and a written plan outlining how this violation will be avoided in the future to licensing office by due date.
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This requirement is not met as evidenced by incident report, interviews with staff and review of R1’s records, which showed that the resident was able to wander away from the facility without staff supervision. This is an immediate health/safety risk to persons 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:Andrea Medlin
LICENSING EVALUATOR NAME:John Calandra
LICENSING EVALUATOR SIGNATURE:
DATE: 09/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/27/2024


LIC809 (FAS) - (06/04)
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