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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600809
Report Date: 11/03/2023
Date Signed: 11/03/2023 04:05:18 PM

Document Has Been Signed on 11/03/2023 04:05 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:JANIE'S HOMEFACILITY NUMBER:
415600809
ADMINISTRATOR:MURPHY, MAY MITZIFACILITY TYPE:
740
ADDRESS:197 FLYING CLOUD ISLETELEPHONE:
(650) 349-2943
CITY:FOSTER CITYSTATE: CAZIP CODE:
94404
CAPACITY: 6CENSUS: 4DATE:
11/03/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Administrator, May Mitzi MurphyTIME COMPLETED:
04:10 PM
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On November 3, 2023, Licensing Program Analyst (LPA) conducted an unannounced visit to follow up with the plan of correction (POC) that was submitted by the administrator/Licensee, May Mitzi Murphy. LPA met with the administrator and explained the purpose of today's visit.

On October 19, 2023 LPA conducted an unannounced visit to deliver the findings in reference to complaint # 14-AS-20230901133006 and observed the assistant administrator, staff #1 (S1) and staff #2 (S2) did not have their personnel files, and S1 was not associated with the facility and not fingerprinted cleared.

During today's POC visit, LPA observed staff #3 (S3) was providing care to resident #1(R1) and administrator was not able to provide S3's personnel file to review as the administrator stated that this person/staff only today.

Due to the above observation and deficiency not being corrected, a civil penalty is being assessed in the amount of $100 a day from 10/21/2023 through 11/2/2023 and will continue to accrue until corrected.

A total civil penalty of $2,800 is being assessed.

This report is reviewed and discussed with the assistant administrator. A copy of this report and appeal rights were provided.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE: DATE: 11/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/03/2023
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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