Community Care Licensing

SUPERVISOR'S NAME: April Cowan TELEPHONE: (650) 266-8889 LICENSING EVALUATOR NAME: Audrey Jeung TELEPHONE: (650) 266-8891 LICENSING EVALUATOR SIGNATURE: DATE: 09/03/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/03/2024

Document Has Been Signed on 09/03/2024 05:05 PM - It Cannot Be Edited

FACILITY NAME: GEORGE ANNE HOME	FACILITY NUMBER: 415600966
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/03/2024

Type A

Section Cited

CCR

87303(e)(2)

(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
1 2 3 4	Based on observation, the licensee did not comply with the section cited above, as hot water temperature tested at 128 degrees in rear common bathroom. This poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 09/04/2024
	Plan of Correction
1 2 3 4	Hot water temperature to be lowered and maintained between 105 and 120 degrees at all times. Proof of correction to be sent to CCLD BY DUE DATE. This deficiency was cited during annual inspection in 2023.

Type A

Section Cited

CCR

87309(a)

(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
1 2 3 4	Based on observation, the licensee did not comply with the section cited above, as cleaning liquids are stored where accessible to clients. In bathroom in room #1 and common bathroom, purple liquid Fabuloso is stored. Pine Sol, degreaser, and other cleaning liquids are stored in unlocked cabinet under kitchen sink, and gallon of Clorox bleach observed in backyard in gazebo. This poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 09/04/2024
	Plan of Correction
1 2 3 4	Cleaning products will be secured and inaccessible to clients. Proof/plan of correction to be submitted to CCLD BY DUE DATE, This deficiency was cited during annual inspection in 2023.

SUPERVISOR'S NAME: April Cowan TELEPHONE: (650) 266-8889 LICENSING EVALUATOR NAME: Audrey Jeung TELEPHONE: (650) 266-8891 LICENSING EVALUATOR SIGNATURE: DATE: 09/03/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/03/2024

Document Has Been Signed on 09/03/2024 05:05 PM - It Cannot Be Edited

FACILITY NAME: GEORGE ANNE HOME	FACILITY NUMBER: 415600966
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/03/2024

Section Cited

	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date:
	Plan of Correction
1 2 3 4

Type A

Section Cited

CCR

87465(h)(2)

(h) The following requirements shall apply to medications which are centrally stored: (2) 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
1 2 3 4	Based on observation, the licensee did not comply with the section cited above, as clients' medications are stored in unlocked cabinets in hallway and kitchen, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 09/04/2024
	Plan of Correction
1 2 3 4	Clients' medications will be stored where they are inaccessible to residents. Proof of correction to be sent to CCLD BY DUE DATE. This deficiency was cited during annual inspection in 2023.

SUPERVISOR'S NAME: April Cowan TELEPHONE: (650) 266-8889 LICENSING EVALUATOR NAME: Audrey Jeung TELEPHONE: (650) 266-8891 LICENSING EVALUATOR SIGNATURE: DATE: 09/03/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/03/2024

Document Has Been Signed on 09/03/2024 05:05 PM - It Cannot Be Edited

FACILITY NAME: GEORGE ANNE HOME	FACILITY NUMBER: 415600966
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/03/2024

Type B

Section Cited

CCR

87411(f)

(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on staff records review, the licensee did not comply with the section cited above in 3 out of 6 staff files reviewed, which poses a potential health, safety or personal rights risk to persons in care. There is no health screening and TB test result for staff #2 and #3. Staff #1 has no health screening on file.
	POC Due Date: 09/17/2024
	Plan of Correction
1 2 3 4	Health screenings and/or TB test results for staff #1, #2, #3 to be sent to CCLD BY DUE DATE

SUPERVISOR'S NAME: April Cowan TELEPHONE: (650) 266-8889 LICENSING EVALUATOR NAME: Audrey Jeung TELEPHONE: (650) 266-8891 LICENSING EVALUATOR SIGNATURE: DATE: 09/03/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/03/2024

Document Has Been Signed on 09/03/2024 05:05 PM - It Cannot Be Edited

FACILITY NAME: GEORGE ANNE HOME	FACILITY NUMBER: 415600966
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/03/2024

Type B

Section Cited

HSC

1569.625(b)(2)

(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Citation deleted
	POC Due Date: 09/17/2024
	Plan of Correction
1 2 3 4	NA

Type B

Section Cited

HSC

1569.696(a)

(a) All residential care facilities for the elderly 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. The training shall include all of the following: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on staff records review, the licensee did not comply with the section cited above, as there is no documentation that staff received 4 hours of training on postural supports, restricted health conditions, and hospice care. This poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/17/2024
	Plan of Correction
1 2 3 4	Staff will receive required 4 hours of training as specified, and proof of training to be sent to CCLD BY DUE DATE.

SUPERVISOR'S NAME: April Cowan TELEPHONE: (650) 266-8889 LICENSING EVALUATOR NAME: Audrey Jeung TELEPHONE: (650) 266-8891 LICENSING EVALUATOR SIGNATURE: DATE: 09/03/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/03/2024

Document Has Been Signed on 09/03/2024 05:05 PM - It Cannot Be Edited

FACILITY NAME: GEORGE ANNE HOME	FACILITY NUMBER: 415600966
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/03/2024

Type B

Section Cited

HSC

1569.69(a)

(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on staff records review, the licensee did not comply with the section cited above, as there is no documentation that staff who handle or manage medications have received required medications training. This poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/17/2024
	Plan of Correction
1 2 3 4	Staff who handle medications shall receive required medications training, and proof of training to be sent to CCLD BY DUE DATE. This shall include 10 hours of initial training, consisting of 6 hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medications, and 4 hours of other training or instruction, as described in subdivision (f), which shall be completed within the first two weeks of employment.

Type B

Section Cited

CCR

87468(b)(1)(A)

(b) At the time the admission agreement is signed, a resident and the resident's representative shall be personally advised of and given a copy of: (1) The personal rights of residents specified in Sections 87468.1, Personal Rights of Residents in All Facilities and 87468.2, Additional Personal Rights of Residents in Privately Operated Facilities, as applicable to the facility. (A) The licensee shall have each resident and the resident's representative sign a copy of these rights, and the signed copy shall be included in the resident's record. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on client records review, the licensee did not comply with the section cited above in 2 out of 6 client files reviewd, which poses a potential health, safety or personal rights risk to persons in care. Personal rights forms are incomplete or missing for clients #1 and #2.
	POC Due Date: 09/17/2024
	Plan of Correction
1 2 3 4	Personal Rights forms shall be completed, signed, and dated for clients #1 and #2. Copies will be sent to CCLD BY DUE DATE.

SUPERVISOR'S NAME: April Cowan TELEPHONE: (650) 266-8889 LICENSING EVALUATOR NAME: Audrey Jeung TELEPHONE: (650) 266-8891 LICENSING EVALUATOR SIGNATURE: DATE: 09/03/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/03/2024

Document Has Been Signed on 09/03/2024 05:05 PM - It Cannot Be Edited

FACILITY NAME: GEORGE ANNE HOME	FACILITY NUMBER: 415600966
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/03/2024

Type B

Section Cited

CCR

87457(c)

(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on client records review, the licensee did not comply with the section cited above in 1 out of 6 client files reviewed, which poses a potential health, safety or personal rights risk to persons in care. There is no appraisal on file for client #5, who was admitted over 2 years ago.
	POC Due Date: 09/17/2024
	Plan of Correction
1 2 3 4	Appraisal for client #5 will be completed, signed and dated, and copy will be sent to CCLD BY DUE DATE.

Type B

Section Cited

HSC

1569.695(b)

(b) A facility shall provide training on the plan to each staff member upon hire and annually thereafter. The training shall include staff responsibilities during an emergency or disaster. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on staff records review, the licensee did not comply with the section cited above, as staff have not received training on responding to emergencies. This poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/17/2024
	Plan of Correction
1 2 3 4	Staff shall receive emergency response training, and proof of correction to be sent to CCLD BY DUE DATE

SUPERVISOR'S NAME: April Cowan TELEPHONE: (650) 266-8889 LICENSING EVALUATOR NAME: Audrey Jeung TELEPHONE: (650) 266-8891 LICENSING EVALUATOR SIGNATURE: DATE: 09/03/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/03/2024

Document Has Been Signed on 09/03/2024 05:05 PM - It Cannot Be Edited

FACILITY NAME: GEORGE ANNE HOME	FACILITY NUMBER: 415600966
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/03/2024

Type B

Section Cited

HSC

1569.695(c)

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on absence of documentation and confirmation from staff, the licensee did not comply with the section cited above, as there is no documentation that of emergency drills. This poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/17/2024
	Plan of Correction
1 2 3 4	Emergency disaster drills will be conducted at least quarterly and documented. REcord of emergency drill be to sent to CCLD BY DUE DATE.

Type B

Section Cited

CCR

87608(a)(3)

(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions: (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident's record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on client records review, the licensee did not comply with the section cited above in 6 out of 6 client files reviewed, which poses a potential health, safety or personal rights risk to persons in care. All clients have half bed rails on bed, but there are no MD orders on file.
	POC Due Date: 09/17/2024
	Plan of Correction
1 2 3 4	MD orders for half bed rails for all clients will be sent to CCLD BY DUE DATE

SUPERVISOR'S NAME: April Cowan TELEPHONE: (650) 266-8889 LICENSING EVALUATOR NAME: Audrey Jeung TELEPHONE: (650) 266-8891 LICENSING EVALUATOR SIGNATURE: DATE: 09/03/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/03/2024

Document Has Been Signed on 09/03/2024 05:05 PM - It Cannot Be Edited

FACILITY NAME: GEORGE ANNE HOME	FACILITY NUMBER: 415600966
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/03/2024

Type B

Section Cited

CCR

87705(c)(3)(A)

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (3) In addition to the on-the-job training requirements in Section 87411(d), staff who provide direct care to residents with dementia shall receive the following training as appropriate for the job assigned and as evidenced by safe and effective job performance: (A) Dementia care including, but not limited to, knowledge about hydration, skin care, communication, therapeutic activities, behavioral challenges, the environment, and assisting with activities of daily living; This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on review of staff training records, the licensee did not comply with the section cited above, as there is no evidence that staff have received required dementia training. This poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/17/2024
	Plan of Correction
1 2 3 4	Staff will receive required dementia training. Proof of training to be sent to CCLB BY DUE DATE.

Type B

Section Cited

CCR

87705(c)(5)

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on review of client records, the licensee did not comply with the section cited above in 4out of 6 client files reviewed, which poses a potential health, safety or personal rights risk to persons in care. Clients #1, #3, #4, #6 are diagnosed with dementia, but MD reports and appraisals are dated more than 12 months ago.
	POC Due Date: 09/17/2024
	Plan of Correction
1 2 3 4	MD reports and/or appraisals for clients #1, #3, #4, #6 will be completed and copies to be sent to CCLD BY DUE DATE.

SUPERVISOR'S NAME: April Cowan TELEPHONE: (650) 266-8889 LICENSING EVALUATOR NAME: Audrey Jeung TELEPHONE: (650) 266-8891 LICENSING EVALUATOR SIGNATURE: DATE: 09/03/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/03/2024

Document Has Been Signed on 09/03/2024 05:05 PM - It Cannot Be Edited

FACILITY NAME: GEORGE ANNE HOME	FACILITY NUMBER: 415600966
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/03/2024

Type B

Section Cited

CCR

87468.2(a)(1)

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
1 2 3 4	Based on observation, the licensee did not comply with the section cited above, as there is a chair used to weigh all clients stored in room #4 for lack of a common storage area for the chair. This poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/17/2024
	Plan of Correction
1 2 3 4	Scale chair will be removed from client's room and stored in facility storage area, not in client rooml Proof of correction to be sent to CCLD BY DUE DATE. This deficiency was cited during annual visit in 2023.

Type B

Section Cited

CCR

87303(A)

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above, as there are discarded walkers, mattresses, furniture and 13 oxygen tanks in backyard, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/17/2024
	Plan of Correction
1 2 3 4	Backyard will be cleared of discarded furnishings and proof of correction to be sent to CCLD BY DUE DATE.

SUPERVISOR'S NAME: April Cowan TELEPHONE: (650) 266-8889 LICENSING EVALUATOR NAME: Audrey Jeung TELEPHONE: (650) 266-8891 LICENSING EVALUATOR SIGNATURE: DATE: 09/03/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/03/2024