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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600966
Report Date: 08/14/2025
Date Signed: 08/15/2025 10:19:28 AM

Document Has Been Signed on 08/15/2025 10:19 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: 5DATE:
08/14/2025
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Catalina Guimarin & Maria Cecilia TamayoTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
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To follow up on deficiencies cited on 7/31/25--for which civil penalty of $100 accrued daily for one deficiency starting on 8/5/25--and 8/5/25, LPA Jeung reviewed corrections that were submitted to licensing office on 8/13/25.

The following deficiencies are corrected, and acknowledgement of corrections is issued--5 pages:

- Section 87204 Limitations - Capacity & Ambulatory Status
Updated MD report for Client #1 states that client is Non-ambulatory
Civil penalty of $700 is assessed today, which represents civil penalty of $100/day for period 8/6/25 through and including 8/12/25. See LIC421FC.

- Section 87608 Postural Supports
MD orders for half bed rails for clients #1, #3, #5, #6 were sent to CCLD

- Section 87506 Resident Records
Emergency information for clients #1, #2, #4 were sent to CCLD

- Section 87411 Personnel Requirements
Proof of current first-aid training for staff #2, #3, #4, #5, #6 sent to CCLD

- 87465 Incidental Medical Care
First-aid manual is observed at facility Continued on next page
NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: Audrey Jeung
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/14/2025
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 HOME
FACILITY NUMBER: 415600966
VISIT DATE: 08/14/2025
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The following deficiencies cited on 7/31/25 still exist, as plan of corrections was not submitted to CCLD:

- CCR 87457(c) Pre-Admission Appraisal
Appraisal for client #5 will be completed, signed and dated BY CLIENT OR REPRESENTATIVE AND FACILITY REPRESENTATIVE
- Health and Safety Code 1569.695(b)
- Health and Safety Code 1569.695(c)
- 87463(a) Reappraisals
Appraisals for all clients will be completed, signed and dated BY CLIENT OR REPRESENTATIVE AND FACILITY REPRESENTATIVE
- CCR 87611(b)(1-3) General Requirements for Allowable Health Conditions
- CCR 87412(a)(1-13) Personnel Records

The following deficiencies cited on 8/5/25 still exist, as plan of corrections was not submitted to CCLD:

- CCR 87468.1(a)(1) Personal Rights
"Explanation" was submitted, but affirmation that clients have the right to NOT be confined in bed was NOT submitted
- Health and Safety Code 1569.69(a)
- Health and Safety Code 1569.626(a)
- Health and Safety Code 1569.696(a)
- CCR 87411(f)
Health screenings were not submitted for 6 staff
- CCR87618(b)(1)(B)
- CCR 87465(h)(1)(4)
- CCR 87468.1(a)(13)
- CCR 87465(i)(1-4)
- CCR 87465(e)(1-4)

Administrator Maria Johnson is advised that failure to correct the cited deficiencies on or before the Plan of Correction due date may result in a civil penalty assessment. As per phone conversation, additional time is needed to submit corrections. Written request shall be submitted to CCLD by close of business TODAY, with requested revised due date.
NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: Audrey Jeung
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2025
LIC809 (FAS) - (06/04)
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