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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415201202
Report Date: 12/11/2024
Date Signed: 12/11/2024 04:50:22 PM

Document Has Been Signed on 12/11/2024 04:50 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/
DIRECTOR:		DELPHINE WILLIAMSFACILITY TYPE:
740
ADDRESS:1515 MADDUX DRIVETELEPHONE:
(650) 369-8383
CITY:REDWOOD CITYSTATE: CAZIP CODE:
94061
CAPACITY: 6CENSUS: 4DATE:
12/11/2024
TYPE OF VISIT:OfficeUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:45 PM
MET WITH:Delphine Williams, Licensee and Mark Williams, AdministratorTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
NARRATIVE
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On December 11, 2024, San Bruno Regional Office conducted a non-compliance conference meeting with
Licensee/Administrator, Delphine Williams and Mark Williams at 2:45 PM.

Present in the meeting was Regional Manager, Vivien Helbling, Licensing Program Manager, April Cowan, and Licensing Program Analyst, John Calandra.

The meeting was called to discuss a serious violation that occurred on 09/04/2024 in which a resident was able to elope from the facility.

During the non-compliance meeting, the following violations were discussed:

-Care of Persons with Dementia
- Basic Services
-Care of Persons with Dementia

During this meeting, the compliance plan was developed and discussed with the licensee which includes more frequent monitoring inspection visits to ensure compliance with this compliance plan and Title 22 Regulations for 2 years. Licensee was provided the link below for resources and guidance to improve facility operations:

https://www.cdss.ca.gov/inforesources/community-care/resource-guide-for-providers.

An LIC421IM form issuing an immediate civil penalty of $500 was provided to Delphine Williams, Licensee. The immediate civil penalty of $500 was issued today due to absence of supervision that occurred on 09/4/2024 in which a resident eloped from the facility without staff supervision.

Deficiencies are cited under California Code of Regulations, Title, 22 cited on the LIC 809D. Failure to correct the deficiencies may result in civil penalties.

Report was reviewed with Licensee/Administrator, Delphine Williams and Mark Williams and a copy of this report and the Appeal Rights are provided.

SUPERVISORS NAME: Andrea Medlin
LICENSING EVALUATOR NAME: John Calandra
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)
Page: 1 of 2
Document Has Been Signed on 12/11/2024 04:50 PM - It Cannot Be Edited


Created By: John Calandra On 12/11/2024 at 08:25 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: 12/11/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/12/2024
Section Cited
CCR
87705(c)(4)

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CCR87705(c)(4) Care of Persons with Dementia: (4) There is an adequate number of direct care staff to support each resident’s physical...

This requirement was not met as evidenced by:
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 Licensee shall develop a plan of operation in writing describing how facility shall ensure that personnel will be adequate in numbers at all times. Licensee stated they will have staff notice the Licensee and Administrator that the staff member is going on break to ensure that the residents are taken care of adequately.
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Based on record review, facility did not have adequate personnel to work at the time of the elopement incident. S1 was taking care of 5 residents at time of incident. This is an immediate health, safety, or personal rights risk to persons in care.
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Type A
12/12/2024
Section Cited
CCR87464(f)

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87464 Basic Services: (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c).

This requirement is not met as evidenced by:
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Licensee shall develop a plan in writing detailing additional staff training that will take place to ensure that care and supervision will be provided to every resident in care. Licensee will continue to conduct appraisals and needs and services plans. Licensee will also adhere to the updated LIC 500.
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Based on interviews, Licensee did not provide care and supervision to a resident diagnosed with Dementia who eloped. Staff were aware resident had eloped from the facility as S1 was providing care to a resident and supervising five residents when R1 eloped from the facility but could not leave persons in care unassisted.
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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: 12/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/11/2024


LIC809 (FAS) - (06/04)
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