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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600135
Report Date: 12/21/2023
Date Signed: 12/21/2023 11:55:13 AM

Document Has Been Signed on 12/21/2023 11:55 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
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:SAN CARLOS ELMSFACILITY NUMBER:
415600135
ADMINISTRATOR:EVANS, SCOTTFACILITY TYPE:
740
ADDRESS:707 ELM STREETTELEPHONE:
(650) 595-1500
CITY:SAN CARLOSSTATE: CAZIP CODE:
94070
CAPACITY: 130CENSUS: 110DATE:
12/21/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Activities Director, Kathleen SullivanTIME COMPLETED:
12:15 PM
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On December 21, 2023, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced case management vist. LPA met with Activities Director, Kathleen Sullivan and explained the purpose of the visit.

The Department is amending the licensing report dated September 22, 2023 for a case management visit in relation to an incident that was reported on May 31, 2023, as per the December 15, 2023 First Level Appeal Response, citation 87355(e)(2) Criminal Record Clearance appeal is granted and the $1,000 civil penalty is dismissed due to facility not having knowledge of change of criminal record clearance status for Staff 1 (S1), however citation 87355(e)(1) will be issued with a $500 civil penalty during the visit as a result of S1 initially having criminal record clearance, there was failure to obtain an exemption for S1 as required as he/she was working at the facility. Furthermore as per the December 15, 2023 First Level Appeal Response, citation 87405(h)(1) Administrator Qualifications and Duties will remain still in effect.  

Deficiency of the Residential Care Elderly California Code of Regulations, Title 22, Division 6 is observed and cited on a LIC 809D. Failure to correct the deficiencies may result in civil penalties.  

Report is reviewed with Activities Director and a copy is provided with appeal rights. A copy of civil penalty is also provided.

SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE: DATE: 12/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/21/2023
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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Document Has Been Signed on 12/21/2023 11:55 AM - It Cannot Be Edited


Created By: Komal Charitra On 12/21/2023 at 11:30 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: SAN CARLOS ELMS
FACILITY NUMBER: 415600135

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/21/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/22/2023
Section Cited
CCR
87355(e)(1)

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87355 Criminal Record Clearance: (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:
(1) Obtain a California clearance or a criminal record exemption as required by the Department or...

Violation of this regulation is not met as evidenced by:
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Licensee/Administrator to create a routine system to ensure staff are cleared to work at the facility and ensure facility is aware when an exemption is required.
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Based on documents reviewed, while S1 initially had criminal record clearance, there was a failure to obtain an exemption as required as S1 was still working at the facility
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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:Komal Charitra
LICENSING EVALUATOR SIGNATURE:
DATE: 12/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/21/2023


LIC809 (FAS) - (06/04)
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