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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600966
Report Date: 07/31/2025
Date Signed: 07/31/2025 07:24:18 PM

Document Has Been Signed on 07/31/2025 07:24 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:
07/31/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:Catalina GuimarinTIME VISIT/
INSPECTION COMPLETED:
07:30 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 tested as operable. First-aid kit is maintained. Medications are stored in hall and kitchen cabinets. Client and staff records are reviewed. Maria Lu Johnson oversees facility operations, but does not have valid 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 8/7/25:

• 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 will be reviewed at a later date, due to time constraints.
NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: Audrey Jeung
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/31/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/31/2025
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 07/31/2025 07:24 PM - It Cannot Be Edited


Created By: Audrey Jeung On 07/31/2025 at 04:41 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: 07/31/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/04/2025
Section Cited
CCR
87204(a)

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LIMITATIONS - CAPACITY & AMBULATORY STATUS
A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including specification of the maximum number of persons who may receive services at any one time.
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Plan/proof of correction to be sent to CCLD BY DUE DATE
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This requirement is not met, as client #1 is determined by MD to be bedridden, but facility is not licensed for bedridden clients. Licensee failed to ensure operation within limits of license, which poses a potential health, safety or personal rights risk to clients in care.
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Type B
08/07/2025
Section Cited
CCR87457c)

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PRE-ADMISSION APPRAISAL
Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of their individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance/Retention LimitS.
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Appraisal for client #5 will be completed, signed and dated BY CLIENT OR REPRESENTATIVE AND FACILITY REPRESENTATIVE, and copy will be sent to CCLD BY DUE DATE
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This requirement is not met, as there is no signed appraisal on file for client #5, who was admitted 3 years ago. This poses a potential health, safety or personal rights risk to clients. This was cited on 9/3/24.
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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: 07/31/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/31/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/31/2025 07:24 PM - It Cannot Be Edited


Created By: Audrey Jeung On 07/31/2025 at 05:00 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: 07/31/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/07/2025
Section Cited
HSC
1569.695(b)

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HEALTH & SAFETY CODE
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 there is no documentation that staff received
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Staff shall receive emergency response training and proof of correction to be sent to CCLD BY DUE DATE
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training on responding to emergencies, which poses a potential health, safety or personal rights risk to clients in care.
This deficiency was cited on 9/3/24 and proof of correction was not submitted.
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Type B
08/07/2025
Section Cited
HSC1569.695(c)

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HEALTH & SAFETY CODE
A facility shall conduct a drill at least quarterly for each shift...type of emergency... shall vary. An actual evacuation...is not required... Documentation... shall include the date, the type of emergency covered...names of staff participating in the drill.
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Proof of correction to be sent to CCLD BY DUE DATE
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This requirement is not met, as documentation of emergency drills does not clearly indicate what was done, which poses a potential health, safety or personal rights risk to clients in care.
This deficiency was cited on 9/3/24 and proof of correction was not submitted.
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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: 07/31/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/31/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/31/2025 07:24 PM - It Cannot Be Edited


Created By: Audrey Jeung On 07/31/2025 at 05:12 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: 07/31/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/07/2025
Section Cited
CCR
87608(a)(3)

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POSTURAL SUPPORTS
A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record.
This requirement is not met, as there are no MD orders maintained for 4 out of 6 clients who have half bed rails. Licensee failed to
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MD orders for half bed rails for clients #1, #3, #5, #6 will be sent to CCLD BY DUE DATE
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maintain MD orders for use of half bed rails, which poses a potential health, safety or personal rights risk to clients in care.
This deficiency was cited on 9/3/24 and proof of correction was not submitted.
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Type B
08/07/2025
Section Cited
CCR87463(h)(1-2)

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REAPPRAISALS
The licensee shall request that all residents receive an annual routine visit with a licensed medical professional... every 12 months...Documentation.. shall be added to the resident's record...of a resident's refusal...shall be added to the resident's record. This requirement is not
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Copies of SIGNED AND DATED MD reports for clients #2, #5, #6 to be sent to CCLD BY DUE DATE.
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met, as MD assessments for 3 out of 6 client were done over 3 years ago or not maintained. Licensee failed to ensure annual MD assessments, which poses a potential health, safety or personal rights risk. NO MD report for C2, MD reports for C5 & C6 dated 2022. This deficiency observed 9/3/24.
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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: 07/31/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/31/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/31/2025 07:24 PM - It Cannot Be Edited


Created By: Audrey Jeung On 07/31/2025 at 05:38 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: 07/31/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/07/2025
Section Cited
CCR
87463(a)

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REAPPRAISALS
The pre-admission appraisal... shall be updated in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition... and to keep the appraisal accurate. This requirement is not met as
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SIGNED AND DATED Reappraisals for ALL clients will be sent to CCLD BY DUE DATE
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reappraisals for ALL clients are missing or dated more than 12 months ago. Licensee failed to ensure that annual reappraisals are done, which poses a potential health, safety or personal rights risk to clients.
This deficiency was observed on 9/3/24 and proof of correction was not submitted.
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Type B
08/07/2025
Section Cited
CCR87506(a)

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RESIDENT RECORDS
Each resident’s record shall contain…Resident's legal name…Social Security number, Date of admission…Last known address, Birthdate, Religious preference, if any…Names, address, and telephone numbers of the resident’s representative … to be notified in case of emergency,
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Emergency information to be completed and copies to be sent to CCLD BY DUE DATE
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Name, address, phone number of physician and dentist to be called in an emergency. This requirement is not met, as there is no emergency informatiion maintained for 3 out of 6 clients, which poses a potential health, safety or personal rights risk. No emergency info for C1, C2, C4
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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: 07/31/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/31/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/31/2025 07:24 PM - It Cannot Be Edited


Created By: Audrey Jeung On 07/31/2025 at 05:59 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: 07/31/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/07/2025
Section Cited
CCR
87611(b)(1)(2)(3)

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GENL REQUIREMNTS HEALTH COND.
The licensee shall complete & maintain a current, written record of care... that includes, but is not limited to... Documentation from the physician of... Stability of the medical condition, Medical condition which requires incidental medical services, Method of
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Plan of correction to be sent to CCLD BY DUE DATE
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intervention...skilled professional...who will perform the procedure if the resident needs assistance; names...phone number of...skilled professionals providing services, Emergency contacts. Client #4 has gall bladder stoma & there is no information about care or condition.
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Type B
08/04/2025
Section Cited
CCR87405(a)

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ADMIN QUALIFICATIONS DUTIES
All facilities shall have a qualified and currently certified administrator. This requirement is not met, as proof of a certified RCFE administrator is not available. Licensee failed to ensure there is a certified RCFE administrator, which poses a
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Proof that facility employs a certified RCFE administrator will be sent to CCLD BY DUE DATE
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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: 07/31/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/31/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/31/2025 07:24 PM - It Cannot Be Edited


Created By: Audrey Jeung On 07/31/2025 at 06:35 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: 07/31/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/07/2025
Section Cited
CCR
87412(a)(1-13)

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PERSONNEL RECORDS
The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain specific information. This requirement is not met, as staff records for 6 out of 6 files reviewed are
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STAFF RECORDS WILL BE MAINTAINED FOR ALL STAFF, AND PROOF THAT REQUIRED STAFF RECORDS ARE MAINTAINED FOR ALL STAFF WILL BE SENT TO CCLD BY DUE DATE
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missing job applications, health screenings, including TB test results, criminal record statements. Licensee failed to ensure required staff records are maintained, which poses a potential health, safety or personal rights risk to clients.
This was observed on 9/3/24 and not corrected.
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Type B
08/04/2025
Section Cited
CCR87411(c)(1)

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PERSONNEL REQUIREMENTS
Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met, as 5 out of 6 staff do not have proof of current first aid training, which poses a potential
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Proof of current first aid training for Staff #2, #3, #4, #5, #6 to be sent to CCLD BY DUE DATE.
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 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: 07/31/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/31/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/31/2025 07:24 PM - It Cannot Be Edited


Created By: Audrey Jeung On 07/31/2025 at 06:48 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: 07/31/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/07/2025
Section Cited
CCR
87465(a)(8)

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INCIDENTAL MEDICAL CARE
... a complete first aid kit shall be maintained and be readily available in a specific location in the facility. The kit shall be...approved by the American Red Cross, or shall contain at least... current edition of a first aid manual approved by
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Current first-aid manual will be maintained and proof of correction to be sent to CCLD BY DUE DATE
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the American Red Cross, the American Medical Association or a state or federal health agency. This requirement is not met, as there is no first-aid manual available, 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: 07/31/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/31/2025


LIC809 (FAS) - (06/04)
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