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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415201928
Report Date: 04/22/2024
Date Signed: 04/22/2024 12:34:57 PM

Document Has Been Signed on 04/22/2024 12:34 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/
DIRECTOR:		MA RIZZI BUIFACILITY TYPE:
734
ADDRESS:2830 MEDINA DRIVETELEPHONE:
(650) 871-2525
CITY:SAN BRUNOSTATE: CAZIP CODE:
94066
CAPACITY: 4CENSUS: 2DATE:
04/22/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Jona Tiu and Luz CanaresTIME VISIT/
INSPECTION COMPLETED:
12:30 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 that oversees facility operations.

The following forms are requested to be updated and returned to CCL by 5/6/24:
• LIC 500 Personnel Report
• LIC 309 Administrative Organization

Emergency Disaster Plan (LIC610D) is provided to LPA.

Deficiency of the California Code of Regulations, Title 22, Division 6, Chapter 8 is observed.
See also two Advisory Notes for technical violations.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Audrey Jeung
LICENSING EVALUATOR SIGNATURE: DATE: 04/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/22/2024
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 04/22/2024 12:34 PM - It Cannot Be Edited


Created By: Audrey Jeung On 04/22/2024 at 12:02 PM
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: SAINT FRANCIS HOME
FACILITY NUMBER: 415201928

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above, as hot water temperature tested at 124 degrees F in client bathroom, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/23/2024
Plan of Correction
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Hot water temperature will be lowered and maintained between 105 and 120 degrees. Proof of correction to be submitted to CCLD BY DUE DATE
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Cara Smith
LICENSING EVALUATOR NAME:Audrey Jeung
LICENSING EVALUATOR SIGNATURE:
DATE: 04/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/22/2024


LIC809 (FAS) - (06/04)
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