<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415201928
Report Date: 04/09/2025
Date Signed: 04/09/2025 03:15:11 PM

Document Has Been Signed on 04/09/2025 03:15 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: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: 3DATE:
04/09/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH:Kaila Branch, Luz Canares, Mara EnriquezTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
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. Full bed rails are installed for all clients' beds, but a facility-wide waiver has not yet been approved. A waiver is maintained for 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 11/25) that oversees facility operations.

It is requested that current control of property (current lease agreement) be sent to CCL by 4/16/25.

Updated Emergency Disaster Plan (LIC610D) is provided to LPA.

Deficiencies of the California Code of Regulations, Title 22, Division 6, Chapter 8 are observed.
See also Advisory Notes for technical violations.
NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: Audrey Jeung
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/09/2025
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 6
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
Page: 2 of 6
Document Has Been Signed on 04/09/2025 03:15 PM - It Cannot Be Edited


Created By: Audrey Jeung On 04/09/2025 at 01:59 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: 04/09/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(c)
Building and Grounds
(c) All outdoor and indoor passageways, stairways, inclines, ramps, open porches and other areas of potential hazard shall be kept free of obstruction.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above, as rear bedroom exit door, which is designated with a lighted exit sign, is blocked by several large boxes stacked in front of it. Front bedroom exit door is also a designated exit, and cannot be opened easily. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/10/2025
Plan of Correction
1
2
3
4
Front and rear bedroom doors shall be kept free of obstructions and easily accessible.
Proof of corrections to be sent to CCLD BY DUE DATE.
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
1
2
3
4
Based on observation, the licensee did not comply with the section cited above, as hot water temperature tested at 130 degrees in bath/shower room, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/10/2025
Plan of Correction
1
2
3
4
Hot water temperature to be lowered and maintained within range of 105 and 120 degrees. Proof of correction to be sent to CCLD BY DUE DATE.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
April Cowan
NAME OF LICENSING PROGRAM MANAGER:
Audrey Jeung
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/09/2025


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 04/09/2025 03:15 PM - It Cannot Be Edited


Created By: Audrey Jeung On 04/09/2025 at 01:59 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: 04/09/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80019(e)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and absence of evidence, the licensee did not comply with the section cited above, as respiratory therapist, staff #7, has regular and direct contact with client #1, but does not have criminal record clearance associated to this facility. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/10/2025
Plan of Correction
1
2
3
4
Criminal record clearance of Staff #7 will be maintained and associated to this facility. Proof of correction to be sent to CCLD BY DUE DATE
Type A
Section Cited
CCR
80076(a)(15)
Food Service
(a) In facilities providing meals to clients, the following shall apply: (15) Pesticides and other similar toxic substances shall not be stored in food storerooms, kitchen areas, food preparation areas, or areas where kitchen equipment or utensils are stored.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above, as large sack of rice is stored on floor of kitchen closet with box of "Rodent Station." This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/09/2025
Plan of Correction
1
2
3
4
Rice was removed from kitchen closet and relocated where it is not located near toxic substances in LPA's presence.
Deficiency corrected and cleared.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
April Cowan
NAME OF LICENSING PROGRAM MANAGER:
Audrey Jeung
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/09/2025


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 04/09/2025 03:15 PM - It Cannot Be Edited


Created By: Audrey Jeung On 04/09/2025 at 01:59 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: 04/09/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(d)
Fixtures, Furniture, Equipment, and Supplies
(d) The licensee shall provide lamps or lights as necessary in all rooms and other areas to ensure the comfort and safety of all persons in the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above, as lighting in bath/shower room is dim and does not safely illuminate the room at night, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/16/2025
Plan of Correction
1
2
3
4
Bathroom lighting will be increased and illuminate room safely.
Proof of correction to be sent to CCLD BY DUE DATE.
Type B
Section Cited
CCR
80069(b)
Clients Medical Assessments
(b) In ARFs, prior to accepting a client into care, the licensee shall obtain and keep on file documentation of the client's medical assessment.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on client record review, the licensee did not comply with the section cited above in 2 out of 3 records reviewed, which poses a potential health, safety or personal rights risk to persons in care.
MD reports for clients #1 and #2 are not signed and/or dated.
POC Due Date: 04/16/2025
Plan of Correction
1
2
3
4
Signed and dated MD reports for clients #1 and #2 will be sent to CCLD BY DUE DATE.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
April Cowan
NAME OF LICENSING PROGRAM MANAGER:
Audrey Jeung
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/09/2025


LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 04/09/2025 03:15 PM - It Cannot Be Edited


Created By: Audrey Jeung On 04/09/2025 at 01:59 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: 04/09/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(k)(1)
Health-Related Services
(k) The following requirements shall apply to medications which are centrally stored: (1) Medication shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above, as numerous Rx client medications in bubblepacks and liquid Rx Cephalexin for client #1 are stored in unlocked drawer in living room, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/09/2025
Plan of Correction
1
2
3
4
RX medications were removed to locked storage area in LPA's presence, for eventual removal from premises.
Deficiency corrected and cleared
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
April Cowan
NAME OF LICENSING PROGRAM MANAGER:
Audrey Jeung
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/09/2025


LIC809 (FAS) - (06/04)
Page: 6 of 6