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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600966
Report Date: 08/05/2025
Date Signed: 08/12/2025 10:23:22 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 08/12/2025 10:23 AM - 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:GEORGE ANNE HOMEFACILITY NUMBER:
415600966
ADMINISTRATOR/
DIRECTOR:		JOHNSON, MARIA LUFACILITY TYPE:
740
ADDRESS:849 N DELAWARE STREETTELEPHONE:
(650) 931-4741
CITY:SAN MATEOSTATE: CAZIP CODE:
94401
CAPACITY: 6CENSUS: 6DATE:
08/05/2025
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Maria JohnsonTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
NARRATIVE
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To complete annual inspection of 7/31/25, LPA Jeung reviewed Centrally Stored Medications Records and staff training records. However, training records are not available to review.

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

Due to multiple and repeated deficiencies cited, information about the CCLD Technical Support Program is recommended and provided to administrator, to provide assistance and training in meeting regulatory requirements. LPA will facilitate referral to TSP assistance upon request from facility.
NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: Audrey Jeung
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/05/2025
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 08/12/2025 10:23 AM - It Cannot Be Edited


Created By: Audrey Jeung On 08/04/2025 at 10:42 AM
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: GEORGE ANNE HOME
FACILITY NUMBER: 415600966

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/05/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/12/2025
Section Cited
HSC
1569.69(a)

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HEALTH AND SAFETY CODE
...employee shall complete 10 hours of initial training...consist of 6 hours of hands-on shadowing training...prior to assisting with the self-administration of medications, & 4 hours of other training or instruction, as described in subdivision (f)...be completed within the first 2 weeks
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Proof of required medication training for all staff will be sent to CCLD BY DUE DATE
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of employment. This requirement is not met, as training records are not available for review. Licensee failed to maintain documentation that staff have received medication training, which poses a potential health, safety or personal rights risk. This was cited on 9/3/24, as staff #6 did not have medication training.
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Type B
08/12/2025
Section Cited
HSC1569.626(a)

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HEALTH AND SAFETY CODE
RCFEs shall meet...training requirements, as described in Section 1569.625, for all direct care staff...12 hours of dementia care training, 6 of which...completed before...working independently with residents, and the remaining 6 hours of
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Proof of required dementia training for all staff will be sent to CCLD BY DUE DATE
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which shall be completed within the first 4 weeks of employment. This requirement is not met, as training records are not available for review. Licensee failed to maintain documentation that staff have received dementia training, which poses a potential health, safety or personall rights risk. This was cited on 9/3/24, as staff #6 did not have dementia 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: 08/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/04/2025


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Created By: Audrey Jeung On 08/04/2025 at 11:08 AM
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: GEORGE ANNE HOME
FACILITY NUMBER: 415600966

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/05/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/12/2025
Section Cited
HSC
1569.696(a)

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HEALTH AND SAFETY CODE
All RCFEs shall provide training to direct care staff on postural supports, restricted conditions or health services, and hospice care as a component of the training requirements specified in Section 1569.625. This requirement is not met, as training records are not available for
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Proof of required training on hospice care, restricted health conditions and postural supports for all staff will be sent to CCLD BY DUE DATE
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review. Licensee failed to maintain documentation that staff have received this training, which poses a potential health, safety or personall rights risk. This was cited on 9/3/24 and not corrected, as staff #6 did not have proof of training on hospice care, restricted health conditions.
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Type B
08/12/2025
Section Cited
CCR87411(f)

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PERSONNEL REQUIREMENTS
... verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than 6 months prior to or 7 days after employment or licensure. A report shall be made of each screening, signed by the examining physician.
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Copies of health screenings and TB test results for all staff will be sent to CCLD BY DUE DATE
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This requirement is not met, as 6 out of 6 staff files were missing health screenings and TB test results. Licensee failed to ensure that health screenings are maintained for all staff, which poses a potential health, safety or personal rights risk. This was cited on 9/3/24 and not corrected.
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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: 08/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/04/2025


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Created By: Audrey Jeung On 08/04/2025 at 11:16 AM
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: GEORGE ANNE HOME
FACILITY NUMBER: 415600966

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/05/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/12/2025
Section Cited
CCR
87618(b)(1)(B)

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OXYGEN ADMINISTRATION
..."No Smoking-Oxygen in Use" signs shall be posted in the appropriate areas.
This requirement was not met, as there were no oxygen in use signs posted on 7/31/25 during initial annual inspection, which poses a potential health, safety or personal rights risk.
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Oxygen in use signs will be posted at entrance and bedroom door.
Proof of correction to be sent to CCLD BY DUE DATE.
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Type B
08/12/2025
Section Cited
CCR87465(h)(1)(4)

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INCIDENTAL MEDICAL CARE
All centrally stored medications shall be labeled and maintained in compliance with state and federal laws. No persons other than the dispensing pharmacist shall alter a prescription label. This requirement is not met, as staff write on RX labels. Licensee
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Staff shall cease writing on Rx labels. Plan/proof of correction to be sent to CCLD BY DUE DATE.
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failed to ensure that staff do not write on Rx labels, 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: 08/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/04/2025


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Created By: Audrey Jeung On 08/05/2025 at 12:09 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: GEORGE ANNE HOME
FACILITY NUMBER: 415600966

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/05/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/06/2025
Section Cited
CCR
87468.1(a)(1)

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PERSONAL RIGHTS
Residents in all RCFEs shall have... the ... personal right to be accorded safe, healthful &comfortable accommodations, furnishings & equipment. This requirement is not met, as client in room #5 is observed in bed with recliner chair
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Clients cannot be restricted from getting out of bed. Recliner and wheelchair were relocated in LPA's presence.
Plan of correction shall be submitted to CCLD BY DUE DATE, affirming that clients have the right to not be confined in bed.
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and wheelchair placed next to bed, preventing her from getting out of bed. Licensee failed to ensure that clients are accorded safe & healthful accommodations, which poses an immediate 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: 08/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/05/2025


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Document Has Been Signed on 08/12/2025 10:23 AM - It Cannot Be Edited


Created By: Audrey Jeung On 08/05/2025 at 12:39 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: GEORGE ANNE HOME
FACILITY NUMBER: 415600966

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/05/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/12/2025
Section Cited
CCR
87468.1(a)(13)

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PERSONAL RIGHTS
Residents in all RCFEs shall have the personal right to have access to individual storage space for private use. This requirement is not met, as facility records are stored in client room #4. Licensee failed to ensure that client's
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Clients' rooms will be reserved for clients' belongings only, and not for storage of facility equipment or supplies.
Plan/proof of correction to be sent to CCLD BY DUE DATE.
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room is for client's personal use and not used by staff. This poses a potential health, safety or personal rights risk to clients in care.
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Type B
08/12/2025
Section Cited
CCR87465(i)(1-4)

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INCIDENTAL MEDICAL CARE
Rx medications which are not taken with the resident upon termination of services, not returned to the issuing pharmacy, nor retained in the facility as ordered by the resident’s physician & documented in the resident’s record nor disposed of... shall be destroyed in the facility by the facility
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Medications of former residents must be destroyed, and witnessed and documented as per requirements.
Proof of correction to be sent to CCLD BY DUE DATE.
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administrator & another adult who is not a resident. Both shall sign a record, to be retained for at least 3 years, which lists... specific information. This requirement is not met, as Rx meds for former client observed in kitchen cabinet, which poses a potential health, safety or personal rights risk.
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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: 08/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/05/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/12/2025 10:23 AM - It Cannot Be Edited


Created By: Audrey Jeung On 08/05/2025 at 01:04 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: GEORGE ANNE HOME
FACILITY NUMBER: 415600966

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/05/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/12/2025
Section Cited
CCR
87465(e)(1-4)

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INCIDENTAL MEDICAL CARE
For every Rx and non Rx medication for which the licensee provides assistance there shall be a signed, dated written order from a physician, on a prescription blank, maintained in the residents file, and a label on the medication. Both the
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MD orders for C3 Senna and C6 Senna Plus to be sent to CCLD BY DUE DATE.
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physician's order and the label shall contain ...specific information. This requirement is not met, as MD orders are not maintained for C3 OTC Senna and C6 Senna Plus. Licensee failed to ensure that MD orders are maintained for OTC meds, which poses a potential health, safety or personal rights risk
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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: 08/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/05/2025


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