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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600809
Report Date: 11/16/2023
Date Signed: 11/16/2023 12:53:26 PM

Document Has Been Signed on 11/16/2023 12:53 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: 5DATE:
11/16/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Administrator, and Assistant Administrator, Mitzi Murphy, Shalimar LardizabalTIME COMPLETED:
01:05 PM
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On November 16, 2023, Licensing Program Analyst (LPA) conducted an unannounced Plan of Correction (POC) visit to follow up on deficiencies cited on November 1, 2023 during a case management visit and complaint visit on October 19, 2023.

Upon arrival, LPA was greeted by caregiver, Aldelyn Batara and administrator, Mitzi Murphy and LPA explained the purpose of the visit. The assistant administrator arrived shortly thereafter to assist with the visit.

During today's visit, LPA toured the facility and review files.

During the tour, LPA observed 5 residents (4 eating lunch in the dining room and 1 in the room) and 3 facility staff (administrator, assistant administrator and caregiver) and LPA did not observed any additional adults. LPA observed facility to be cleaned and tidy, there was no apparent noise from the construction, and required poster posted on the wall by the medication/office.

In regards to the room in the garage, the assistant administrator stated that facility will pay for the inspection fee today and the room will not be used as a live-in space for staff as of 11/16/2023 until the inspection by City of Foster City.

Based on documents provided, LPA reviewed 4 out of 4 personnel files to be adequate.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE: DATE: 11/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/16/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 HOME
FACILITY NUMBER: 415600809
VISIT DATE: 11/16/2023
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The following deficiencies are cleared:

87412 Personnel Records..(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

87405 Administrator - Qualifications and Duties..(d) The administrator shall have the qualifications..(2) Knowledge of and ability to conform to the applicable laws, rules and regulations...

87355 Criminal Record Clearance..(e) All individuals subject to a criminal record the Department

87305 Alterations to Existing Building or New Facilities... (a)Prior to construction or alterations, all facilities shall obtain a building permit.

87468.1 Personal Rights of Residents in All Facilities..(a) Residents in all residential care facilities shall have all of the following personal rights:..(2) To be accorded safe, healthful and comfortable accommodations..

87303 Maintenance and Operation..a) The facility shall be clean, safe, sanitary and in good repair at all times

87468.1 Personal Rights of Residents in All Facilities..(a) Residents in all residential care facilities.. shall have all of the following personal rights:4) To be informed by the licensee of the provisions of law regarding complaints and of procedures for confidentially registering complaints,..

Report is reviewed with the assistant administrator; POC letter is generated and provided on this day.

A copy of this report is provided.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2023
LIC809 (FAS) - (06/04)
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