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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600679
Report Date: 10/21/2023
Date Signed: 10/21/2023 01:46:50 PM


Document Has Been Signed on 10/21/2023 01:46 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:VICTORIAFACILITY NUMBER:
415600679
ADMINISTRATOR:JOHNSON, ELAINEFACILITY TYPE:
740
ADDRESS:1252 CRESTWOOD DRIVETELEPHONE:
(650) 307-9586
CITY:SOUTH SAN FRANCISCOSTATE: CAZIP CODE:
94080
CAPACITY:5CENSUS: 5DATE:
10/21/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Elaine N. JohnsonTIME COMPLETED:
01:45 PM
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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to conduct a Required – 1 Year inspection on 10/21/23 at 10:45am. LPA met with Agnes Smith, Caregiver who contacted the Administrator who arrived within 15 minutes to assist with todays visit. LPA was allowed entry into the facility that is licensed to serve a total capacity of 5 non-ambulatory residents of which 2 may receive hospice care services. Annual Fees are current. The administrator certificate for Elaine N. Johnson expires 1/17/24. Facility staff roster provided during this visit. There are 0 residents receiving hospice care services during this visit. The caregiver(s) are fingerprint cleared and associated to the facility.

LPA toured and inspected the physical plant inside and outside to ensure there are no safety hazards to residents. The temperature inside the facility was observed to be at 69*F which is within the required range of 68-85*F. The hot water temperature was measured at 119.6*F which is within the required range of 105-120*F. LPA observed fire extinguisher(s), pull alarm system, smoke and carbon monoxide detectors in the facility. LPA observed the centrally stored medications area to be locked and inaccessible to residents.
The first aid kit contained the required items such as sterile dressings, bandages, adhesive tape, scissors, tweezers, thermometers, antiseptic solution and guide. LPA observed 2-day perishables and 7-day non-perishables.

LPA observed 2 staff files and 2 resident files and conducted interviews during this visit.

Upon a file review the following items were discussed to be submitted with any changes annually:
Any addendums to the Infection Control Plan, Designation of Facility Responsibility (LIC308), Personnel Report (LIC500) to include the Administrator presence in the facility, Administrator Certificate-Updated, and Liability Insurance.
Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies are being cited
An exit interview was conducted, a copy of the report was given.
SUPERVISOR'S NAME: Victoria BrownTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Victoria BrownTELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:
DATE: 10/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/21/2023
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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