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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 04:16:53 PM

Document Has Been Signed on 11/03/2023 04:16 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:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Administrator, May Mitzi MurphyTIME COMPLETED:
04:25 PM
NARRATIVE
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On November 3, 2023, Licensing Program Analyst (LPA) conducted an unannounced visit to follow up on the plan of correction (POC) that was submitted by the administrator/Licensee, Mitzi Murphy. LPA met with the administrator and explained the purpose of today's visit.

During today's visit, LPA observed staff #1 (S1) was assisting the administrator with providing care to resident #1(R1), however, the administrator was not able to provide S1's personnel file and criminal background clearance record to LPA for review as the administrator stated that this staff only worked today and the facility is experiencing staffing shortage. Administrator asked S1 to leave the facility during visit.

A civil penalty of $100 per day x 1 day = $100 is being assessed.

A civil penalty of $250 is being assessed for repeat violation.

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: 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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Document Has Been Signed on 11/03/2023 04:16 PM - It Cannot Be Edited


Created By: Murial Han On 11/03/2023 at 03:13 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: 11/03/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/06/2023
Section Cited
CCR
87355(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 $100 is being assessed today.

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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: 11/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/03/2023


LIC809 (FAS) - (06/04)
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