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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600809
Report Date: 10/19/2023
Date Signed: 10/19/2023 02:41:13 PM

Document Has Been Signed on 10/19/2023 02:41 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:
10/19/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:20 PM
MET WITH:Assistant Administrator, Shalimar LardizabalTIME COMPLETED:
02:50 PM
NARRATIVE
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On October 19, 2023 Licensing Program Analysts (LPA) Murial Han conducted an unannounced visit to deliver the findings in reference to complaint # 14-AS-20230901133006 and during the visit, LPA made the following observation. LPA met with assistant administrator and explained the purpose of the visit.

During today's visit, LPA requested to reviewed staff #1 (S1) and staff #2 (S2) and assistant administrator's personnel files.

According to the assistant administrator and the administrator, both S1 and S2 have been working at the facility since September 1, 2023 and the facility does have their files as the facility is in the process of getting their files together. In addition, S1 is not associated with the facility and not fingerprint cleared.

This violation results in a civil penalty of $100 per day x 5 day = $500

Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC809-D. Failure to correct the deficiencies may result in additional civil penalties.

Report is reviewed with assistant administrator and a copy is provided with civil penalties and appeal rights.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE: DATE: 10/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/19/2023
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 10/19/2023 02:41 PM - It Cannot Be Edited


Created By: Murial Han On 10/19/2023 at 01:38 PM
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: JANIE'S HOME
FACILITY NUMBER: 415600809

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/20/2023
Section Cited
CCR
87412(a)

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87412Personnel 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:
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The administrator/licensee will develop a plan to ensure compliance and in the plan, it shall indicate the date that the files will be completed by S1 and S2. The administrator will provide a copy of the signed and dated
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This requirement is not met as evidenced by facility did not have S1 and S3's personnel files which poses an immediate health risks to resident in care.
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plan to CCL by 10/20/2023.
Type A
10/20/2023
Section Cited
CCR87355(e)(1)

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87355 Criminal Record Clearance..(e) All individuals subject to a criminal record review..(1) Obtain a California clearance or a criminal record exemption as required by the Department
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S1 was immediately sent home during LPAs visit. Licensee will ensure fingerprints and associations are up to date.
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This requirement is not met as evidenced by LPA observed S1 to be not fingerprint cleared which poses an immediately health risk to residents in care.
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A civil penalty of $500 is being assessed today.
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:Murial Han
LICENSING EVALUATOR SIGNATURE:
DATE: 10/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/19/2023


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 10/19/2023 02:41 PM - It Cannot Be Edited


Created By: Murial Han On 10/19/2023 at 01:51 PM
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: JANIE'S HOME
FACILITY NUMBER: 415600809

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/20/2023
Section Cited
CCR
87405(d)(2)

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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...This requirement is not met as evidenced by
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The administrator will reviewed all the regulations that are cited today and will provide a signed/dated statement of acknowledgement after the review.

The administrator will submit a copy
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The administrator failed to ensure facility staff personnel files are adequate and staff is fingerprint cleared and associated prior to employment which poses an immediate health risks to resident in care.
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of the signed/dated acknowledgement to CCL by 10/20/2023.

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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:Murial Han
LICENSING EVALUATOR SIGNATURE:
DATE: 10/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/19/2023


LIC809 (FAS) - (06/04)
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