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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600966
Report Date: 07/17/2023
Date Signed: 07/17/2023 07:19:07 PM


Document Has Been Signed on 07/17/2023 07:19 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:GEORGE ANNE HOMEFACILITY NUMBER:
415600966
ADMINISTRATOR:JOHNSON, MARIA LUFACILITY TYPE:
740
ADDRESS:849 N DELAWARE STREETTELEPHONE:
(650) 931-4741
CITY:SAN MATEOSTATE: CAZIP CODE:
94401
CAPACITY:6CENSUS: 6DATE:
07/17/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Maria JohnsonTIME COMPLETED:
07:30 PM
NARRATIVE
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LPA Audrey Jeung toured facility and grounds. There are no accessible bodies of water or fire safety hazards observed. A comfortable room temperature is maintained, and lighting is sufficient for safety. Carbon monoxide detector is tested and operable. First-aid kit is maintained and complete.
This one level facility has 6 client bedrooms, 3 full bathrooms, kitchen/living/dining room. There is a detached staff unit/building that contains a bedroom with one bed, a large room with 2 bunk beds, kitchen, and full bathroom for staff. Awake night staff is employed. Two additional detached storage sheds are in the backyard, and washer and dryer are located in an alcove adjacent to staff unit/building. The backyard is level, paved and landscaped. Some medications are stored in locked hall cabinet and chemicals and cleaners are stored in a detached storage shed.
A Disaster and Mass Casualty Plan is posted. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed.
Maria Lu Johnson is a certified RCFE administrator (x 7/24) that oversees facility operations.

Client records and staff training records will be reviewed at a later date.

The following forms are provided and shall be completed and returned to CCL by 7/31/23:
• LIC 308 Designation of Administrative Responsibility (signed by licensee designating administrator)
• LIC 500 Personnel Report
• LIC 610 Emergency Disaster Plan (page 9, signed and dated)
• Infection Control Plan (signed and dated)
• Proof of liability insurance for $1 million per incident and $3 million in annual aggregate
• Staff medication training policy (per H & S 1569.69)

Deficiencies of the CA Code of Regulations, Title 22 are cited on following pages.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:
DATE: 07/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/17/2023
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 07/17/2023 07:19 PM - It Cannot Be Edited

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: GEORGE ANNE HOME
FACILITY NUMBER: 415600966

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/17/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above, as hot water temperature tested at 125 degrees F in middle common bathroom, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/18/2023
Plan of Correction
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Hot water temperature shall be lowered and maintained between 105 and 120 degrees F. Proof of correction to be sent to CCLD BY DUE DATE
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation with administrator,two cans of paint and lighter fluid are stored in unlocked rear storage shed with sliding door and general cleaning supplies and chemicals are stored in another unlocked storage shed with double doors. The licensee did not comply with the section cited above, as toxins were stored where items are accessible to clients, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/17/2023
Plan of Correction
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Paint cans and lighter fluid were moved to storage shed with double doors, and this shed was locked in LPA's presence.
Deficiency corrected and cleared.
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 SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:
DATE: 07/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/17/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/17/2023 07:19 PM - It Cannot Be Edited

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: GEORGE ANNE HOME
FACILITY NUMBER: 415600966

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/17/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:

This requirement is not met as evidenced by:
Deficient Practice Statement
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All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility, obtain a California clearance or a criminal record exemption as required by the Department. Based on presence of staff J.G.who does not have criminal record clearance, the licensee did not comply with the section cited above, which poses an immediate health, safety or personal rights risk to persons in care. Staff J.G. completed the application to obtain a criminal record clearance, but clearance has not yet bee granted. Civil penalty of $500 is assessed today--$100/day for maximum 5 days.
POC Due Date: 07/18/2023
Plan of Correction
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Staff J.G. cannot be present in facility unless and until he has obtained criminal record clearance or exemption.
Proof of correction shall be submitted to CCLD BY DUE DATE.
Failure to comply may result in assessment of additional civil penalties.
Type A
Section Cited
CCR
87465(h)(2)

INCIDENTAL MEDICAL CARE
Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, clients' medications that are refrigerated are stored in unlocked small refrigerator in hallway, and excess medications are stored in unlocked drawer in hallway. Licensee failed to ensure that medications are inaccessible to clients, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/18/2023
Plan of Correction
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Clients' medications shall be stored where they are inaccessible to residents. Proof of correction shall be sent to CCLD BY DUE DATE.
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 SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:
DATE: 07/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/17/2023
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 07/17/2023 07:19 PM - It Cannot Be Edited

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: GEORGE ANNE HOME
FACILITY NUMBER: 415600966

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/17/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87468.2(a)(1)
ADDITIONAL PERSONAL RIGHTS
Residents in privately operated residential care facilities for the elderly shall have all of the following personal rights:

(1) To have a reasonable level of personal privacy in accommodations

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, there is a chair used to weigh all clients stored in room #4 for lack of a common storage area for the chair. Licensee failed to ensure client's right to personal accommodations by storing facility equipment in client's room. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/24/2023
Plan of Correction
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Scale chair will be removed from client's room and stored in facility storage area, not in clients' rooms. Proof of correction to be sent to CCLD BY DUE DATE.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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 SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:
DATE: 07/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/17/2023
LIC809 (FAS) - (06/04)
Page: 4 of 4