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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415201928
Report Date: 08/29/2023
Date Signed: 08/29/2023 12:09:01 PM

Document Has Been Signed on 08/29/2023 12:09 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
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:SAINT FRANCIS HOMEFACILITY NUMBER:
415201928
ADMINISTRATOR:MA RIZZI BUIFACILITY TYPE:
734
ADDRESS:2830 MEDINA DRIVETELEPHONE:
(650) 871-2525
CITY:SAN BRUNOSTATE: CAZIP CODE:
94066
CAPACITY: 4CENSUS: 3DATE:
08/29/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Rizzi BuiTIME COMPLETED:
12:15 PM
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LPA Jeung toured facility and grounds, including, detached garage--where washer and dryer are located-- of this Adult Residential Facility for Persons with Special Healthcare Needs. Facility maintains facility-wide waivers for full bed rails for all clients' beds and alternative assistance with administering PRN medications. Electronic hoyer lifts are installed in all bedrooms and bathroom for lifting residents. There are no accessible bodies of water or fire safety hazards observed. Medications are stored in residents' bedrooms, and toxins and sharps are stored appropriately and inaccessible to clients. A comfortable temperature is maintained. Bathing facilities for clients are equipped with grab bars and nonskid flooring material. Hot water temperature is tested in clients' bathroom. Food and PPE supplies and first-aid kit are inspected. Clients' medications are recorded on Centrally Stored Medications Records, provided by pharmacy. A Disaster and Mass Casualty Plan is posted. There is no staff room, as facility employs awake night staff

Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed, as well as staff records. Rizzi Bui is a certified ARF administrator (x 11/23) that oversees facility operations.

The following forms are requested to be updated and returned to CCL by 9/5/23:
• LIC 500 Personnel Report
• LIC 308 Designation of Facility Responsibility
• LIC 309 Administrative Organization

Emergency Disaster Plan (9 page LIC 610) and proof of current surety bonding are provided to LPA.

No deficiencies of the California Code of Regulations, Title 22, Division 6, Chapter 8 are observed.
See Advisory Notes for technical violation.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Audrey Jeung
LICENSING EVALUATOR SIGNATURE: DATE: 08/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/29/2023
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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