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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600267
Report Date: 07/16/2021
Date Signed: 07/16/2021 11:17:27 AM

Document Has Been Signed on 07/16/2021 11:17 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
CCLD Regional Office,
, CA
FACILITY NAME:WRIGHT PLACE, THEFACILITY NUMBER:
415600267
ADMINISTRATOR:WRIGHT, JO ANNFACILITY TYPE:
740
ADDRESS:2525 ANNAPOLIS ST.TELEPHONE:
(650) 329-0911
CITY:EAST PALO ALTOSTATE: CAZIP CODE:
94303
CAPACITY: 6CENSUS: 4DATE:
07/16/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:51 AM
MET WITH:Jo Ann WrightTIME COMPLETED:
11:40 AM
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required - 1 Year visit and met with Jo Ann Wright.

During visit, LPA Marrufo toured the facility. The facility entrance did not have any materials to screen and log symptoms and temperatures for visitors. LPA Marrufo toured the bedrooms, bathroom, and dinning area. LPA Marrufo observed the facility PPE supply.

LPA Marrufo observed that Administrator Jo Ann Wright's clothes were in a rack in the common hallway. Administrator Jo Ann Wright stated that resident records have not been organized into separate and complete records.

A deficiency was cited as per California Code of Regulations Title 22. See LIC809-D for more information.

Advisory Notes were issued. See LIC9102s for more information.

LPA Marrufo requested updated copies of the following documents:
LIC308 Designation of Administrative Responsibility
LIC610 Emergency Disaster Plan
LIC500 Personnel Report

This report was reviewed with Administrator Jo Ann Wright and a copy of the report and appeal rights were provided.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE: DATE: 07/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/16/2021
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 07/16/2021 11:17 AM - It Cannot Be Edited


Created By: David Marrufo On 07/16/2021 at 10:57 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
,
, CA

FACILITY NAME: WRIGHT PLACE, THE
FACILITY NUMBER: 415600267

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/16/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(a)

(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and records review, the licensee did not comply with the section cited above in 4 out of 4 resident records, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/23/2021
Plan of Correction
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Licensee agrees to create separate, complete, and current records for each resident and submit a proof of correction by POC date to CCL.
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:Jackie Jin
LICENSING EVALUATOR NAME:David Marrufo
LICENSING EVALUATOR SIGNATURE:
DATE: 07/16/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/16/2021


LIC809 (FAS) - (06/04)
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