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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600966
Report Date: 09/10/2026
Date Signed: 09/10/2026 06:26:16 PM

Document Has Been Signed on 09/10/2026 06:26 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: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:
09/10/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:15 PM
MET WITH:Cecilia Tamayo & Catalina GuimarinTIME VISIT/
INSPECTION COMPLETED:
06:30 PM
NARRATIVE
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LPA Audrey Jeung toured facility and grounds, consisting of 6 private 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 spacious backyard is level, paved and landscaped, with 2 gazebos. 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 detectors are present and observed with green lights. First-aid kit is maintained. Medications are stored in hall and kitchen cabinets. Client and some staff records are reviewed. Maria Lu Johnson oversees facility operations, but does not have proof of current RCFE administrator certification. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed. A Disaster and Mass Casualty Plan is posted.

The following forms/information are requested to be updated returned to CCL by 9/24/26:

• LIC 610 Emergency Disaster Plan (page 9, signed and dated)
• Staff medication TRAINING topics (per H & S 1569.69)
• LIC 308 Designation of Facility Responsibility
• LIC 500 Personnel Report
• Proof of current liability insurance

Deficiencies of the CA Code of Regulations, Title 22 are cited on following pages.
Staff training and clients' medications will be reviewed at a later date, due to time constraints.
April Cowan
Audrey Jeung
DATE: 09/10/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/10/2026
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 09/10/2026 06:26 PM - It Cannot Be Edited


Created By: Audrey Jeung On 09/10/2026 at 05:37 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: 09/10/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/11/2026
Section Cited
CCR
87303(e)(2)

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MAINTENANCE AND OPERATION
... 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 and not more than 120 degree F. This requirement is not met, as hot water
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Hot water temperature will be lowered and maintained within range of 105 to 120 degrees F. Proof of correction to be sent to CCLD BY DUE DATE
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temperature tested at 126 degrees F in main client bathroom. Licensee failed to ensure water temperature is maintained within regulatory limits, which poses an immediate health and safety risk to clients in care.
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Type A
09/11/2026
Section Cited
CCR87309(a)

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STORAGE SPACE
...the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked
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Toxics stored in kitchen were moved to locked under sink cabinet and backyard storage shed was padlocked in LPA's presence
Deficiency corrected and cleared.
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 storage. This requirement is not met, as Stove cleaner, kitchen cleaner, Goo Gone, WD-40, wood glue, furniture polish, water proofer are stored in kitchen accessible to clients, & Raid, Ajax cleansers, Clorox are stored in unlocked storage shed in backyard.
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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: 09/10/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/10/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/10/2026 06:26 PM - It Cannot Be Edited


Created By: Audrey Jeung On 09/10/2026 at 05:48 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: 09/10/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/24/2026
Section Cited
CCR
87405(a)

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ADMINISTRATOR QUALIFICATIONS..
All facilities shall have a qualified and currently certified administrator...
This requirement is not met, as there is no proof that a certified administrator is employed. Licensee failed to ensure that a qualified and certified administrator is
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Proof of correction shall be sent to CCLD BY DUE DATE
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employed to manage facility operations, which poses a potential health, safety or personal rights risk to clients in care.
This deficiency was cited on 7/31/25.
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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: 09/10/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/10/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/10/2026 06:26 PM - It Cannot Be Edited


Created By: Audrey Jeung On 09/10/2026 at 06:00 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: 09/10/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/11/2026
Section Cited
CCR
87355(e)(2)

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CRIMINAL RECORD CLEARANCE
All individuals subject to a criminal record review pursuant to HSC 1569.17(b) shall prior to working, residing or volunteering in a licensed facility...Obtain a CA clearance or a criminal record exemption. This requirement is not met, as criminal record clearances for staff #1 and #2 are
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Proof of correction to be sent to CCL BY DUE DATE
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not associated to this facility. Licensee failed to ensure that all staff maintain criminal record clearance and association to facility, 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: 09/10/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/10/2026


LIC809 (FAS) - (06/04)
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