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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600901
Report Date: 08/13/2026
Date Signed: 08/13/2026 03:23:50 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 08/13/2026 03:23 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:DERRY WAY HOME, INC.FACILITY NUMBER:
415600901
ADMINISTRATOR/
DIRECTOR:		KWAI KWONG LIUFACILITY TYPE:
740
ADDRESS:2243 DERRY WAYTELEPHONE:
(650) 219-7930
CITY:SOUTH SAN FRANCISCOSTATE: CAZIP CODE:
94080
CAPACITY: 6CENSUS: 4DATE:
08/13/2026
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:15 PM
MET WITH:Linfang Li and Yvonne KwokTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
NARRATIVE
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To complete annual inspection of 7/31/26, LPA Jeung met with staff in the absence of licensee/administrator and reviewed staff files and clients' medications. Centrally Stored Medication Records are not available for review.

There are 3 residents under age 60 and one resident who is over 60.

Deficiencies of the California Code of Regulations, Title 22 are cited on following pages.

RCFE license is issued to correct licensed capacity, which was initially issued erroneously.
April Cowan
Audrey Jeung
DATE: 08/13/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/13/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 08/13/2026 03:23 PM - It Cannot Be Edited


Created By: Audrey Jeung On 08/13/2026 at 02:02 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: DERRY WAY HOME, INC.
FACILITY NUMBER: 415600901

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/13/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/27/2026
Section Cited
CCR
87463(h)(1)

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REAPPRAISALS
The licensee shall request that all residents receive an annual routine visit with a licensed medical professional once every 12 months, either in person or by video appointment. Documentation of the...visit, such as a visit summary, shall be added to the record.
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Updated, signed, dated MD assessment for client #1 will be sent to CCLD BY DUE DATE
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This requirement is not met, as date of MD report for client #1 is not clearly indicated. Licensee failed to ensure clear records that 1 out of 4 clients has an annual medical evaluation, which poses a potential health, safety or personal rights risk to clients in care.
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Type B
08/27/2026
Section Cited
CCR87465(h)(6)

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INCIDENTAL MEDICAL CARE
A record of centrally stored prescription medications for each resident shall be maintained and include names of the resident for whom prescribed, prescribing physician and pharmacist, drug name, strength and quantity, dates filled, started
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Centrally Stored Medications Records shall at all times be maintained and accessible for licensing staff review.
Proof of correction will be sent to CCLD BY DUE DATE
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& expiration, prescription number and instructions. This requirement is not met, as Centrally Stored Medication Records are not available for review, which poses a potential health, safety or personal rights risk to clients in care.
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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.
April Cowan
NAME OF LICENSING PROGRAM MANAGER:
Audrey Jeung
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/13/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/13/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/13/2026 03:23 PM - It Cannot Be Edited


Created By: Audrey Jeung On 08/13/2026 at 02:16 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: DERRY WAY HOME, INC.
FACILITY NUMBER: 415600901

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/13/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/27/2026
Section Cited
CCR
87411(c)(1)

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PERSONNEL REQUIREMENTS
Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.
This requirement is not met, as first-aid training for 3 out of 5 staff is not current. Licensee failed to ensure that staff who
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First aid training for staff #2, #4, #5 will be completed, and proof of correction will be sent to CCLD BY DUE DATE
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provide care have valid first-aid training, which poses a potential health, safety or personal rights risk to clients in care.
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Type B
08/27/2026
Section Cited
HSC1569.69(b)

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HEALTH AND SAFETY CODE
Each employee who received training and passed the exam required in paragraph (5) of subdivision (a), and who continues to assist with the self-administration of medicines, shall also complete 8 hours of in-service training on medication-related issues in
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Proof of required 8 hours of annual medications training for staff who handle or administer clients' medications will be sent to CCLD BY DUE DATE.
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each succeeding 12-month period. This requirement is not met, as it cannot be verified that all staff have received annual medications training. Licensee failed to ensure that all staff who handle clients' medications has received 8 hours of annual medications training.
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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.
April Cowan
NAME OF LICENSING PROGRAM MANAGER:
Audrey Jeung
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/13/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/13/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/13/2026 03:23 PM - It Cannot Be Edited


Created By: Audrey Jeung On 08/13/2026 at 02:38 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: DERRY WAY HOME, INC.
FACILITY NUMBER: 415600901

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/13/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/27/2026
Section Cited
CCR
87463(a)

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REAPPRAISALS
The pre-admission appraisal... shall be updated in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep
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Updated, signed and dated reappraisals for all clients will be sent to CCLD BY DUE DATE
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the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal. This requirement is not met, as appraisals for all clients are dated more than 12 months ago. Licensee failed to ensure annual appraisals are documented.
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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.
April Cowan
NAME OF LICENSING PROGRAM MANAGER:
Audrey Jeung
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/13/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/13/2026


LIC809 (FAS) - (06/04)
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