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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600983
Report Date: 06/23/2026
Date Signed: 06/25/2026 10:14:54 AM

Document Has Been Signed on 06/25/2026 10:14 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:ANAMARIE CARE HOME LLCFACILITY NUMBER:
415600983
ADMINISTRATOR/
DIRECTOR:		AREVALO, ANA MARIEFACILITY TYPE:
740
ADDRESS:748 WASHINGTON STREETTELEPHONE:
(650) 550-4668
CITY:DALY CITYSTATE: CAZIP CODE:
94015
CAPACITY: 6CENSUS: 4DATE:
06/23/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:00 PM
MET WITH:Anamarie ArevaloTIME VISIT/
INSPECTION COMPLETED:
06:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Audrey Jeung toured facility and grounds, consisting of three shared client bedrooms, two staff rooms--one with a large bed for 2 staff and the other with no bed--two full bathrooms, dining area, TV room, kitchen and living room. A comfortable temperature is maintained and lighting is sufficient for comfort and safety. This is a single story facility with one car garage, where washer and dryer are located. Water temperature is tested in main bathroom. Medications, sharps, and chemicals are observed locked and inaccessible to residents. Food supplies of perishables for 2 days and non-perishables for 7 days are maintained. First aid kit is observed to be complete. Carbon monoxide detector is tested and operable. There are 4 residents present, and 3 staff.

Client records and staff records are reviewed. Ana Marie Avevalo and Jocelyn Maniva are certified RCFE administrators (x 7/26 and x 3/27) that oversee facility operations. Centrally Stored Medication Records will be reviewed at a later date, due to time constraints. Emergency drills are documented as conducted quarterly.

The following information/forms are requested to be submitted to CCLD BY 7/7/26:
- Administrative Organization (LIC309)
- Personnel Report (LIC500)
- Medication training requirements for staff, as per Health and Safety Code 1569.60
- updated Facility Sketch, showing room designations


Deficiencies of the California Code of Regulations, Title 22, are observed. See Technical Advisory Notes --4 pages. Report is reviewed with administrator and a copy is provided.
NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: Audrey Jeung
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/23/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/23/2026
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 06/25/2026 10:14 AM - It Cannot Be Edited


Created By: Audrey Jeung On 06/23/2026 at 05:56 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: ANAMARIE CARE HOME LLC
FACILITY NUMBER: 415600983

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/23/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(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
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Based on observation, the licensee did not comply with the section cited above, as hot water temperature tested at 124 degrees F in main client bathroom, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/24/2026
Plan of Correction
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Plan/proof of correction to be sent to CCLD BY DUE DATE
Type A
Section Cited
CCR
87307(d)(6)
Personal Accommodations and Services
(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above, as rear exit door cannot be accessed, as it is blocked by boxes and furnishings, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/23/2026
Plan of Correction
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Items were removed from area of rear exit door in LPA's presence and is unobstructed.
Deficiency corrected and cleared.
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: 06/23/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/23/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/25/2026 10:14 AM - It Cannot Be Edited


Created By: Audrey Jeung On 06/23/2026 at 05:56 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: ANAMARIE CARE HOME LLC
FACILITY NUMBER: 415600983

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/23/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(1)
Other Provisions
(1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff member shall complete 20 hours, including six hours specific to dementia care, as required by subdivision (a) of Section 1569.626 and four hours specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696, before working independently with residents. The remaining 20 hours shall include six hours specific to dementia care and shall be completed within the first four weeks of employment. The training coursework may utilize various methods of instruction, including, but not limited to, lectures, instructional videos, and interactive online courses. The additional 16 hours shall be hands-on training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on absence of training records, the licensee did not comply with the section cited above, as there is no evidence that staff #2, who was employed 2 months ago, has completed required initial training, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/07/2026
Plan of Correction
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Proof/plan of correction to be sent to CCLD BY DUE DATE

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: 06/23/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/23/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/25/2026 10:14 AM - It Cannot Be Edited


Created By: Audrey Jeung On 06/23/2026 at 05:56 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: ANAMARIE CARE HOME LLC
FACILITY NUMBER: 415600983

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/23/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.626(a)(1)
(a) All residential care facilities for the elderly shall meet the following training requirements, as described in Section 1569.625, for all direct care staff: (1) Twelve hours of dementia care training, six of which shall be completed before a staff member begins working independently with residents, and the remaining six hours of which shall be completed within the first four weeks of employment. All 12 hours shall be devoted to the care of persons with dementia. The facility may utilize various methods of instruction, including, but not limited to, preceptorship, mentoring, and other forms of observation and demonstration. The orientation time shall be exclusive of any administrative instruction.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on absence of training records, the licensee did not comply with the section cited above, as there is no evidence that staff #2, who was employed 2 months ago, has received any dementia training. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/07/2026
Plan of Correction
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4
Proof/plan of correction to be sent to CCLD BY DUE DATE

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: 06/23/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/23/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/25/2026 10:14 AM - It Cannot Be Edited


Created By: Audrey Jeung On 06/23/2026 at 05:56 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: ANAMARIE CARE HOME LLC
FACILITY NUMBER: 415600983

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/23/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(a)
Reappraisals
(a) The pre-admission appraisal, as specified in Section 87457, 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, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on review of client records, the licensee did not comply with the section cited above in 1 out of 4 client records reviewed, which poses a potential health, safety or personal rights risk to persons in care
- appraisal for client #1 is dated in 2022
POC Due Date: 07/07/2026
Plan of Correction
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Updated, completed and signed appraisal for client #1 to be sent to CCLD BY DUE DATE
Type B
Section Cited
CCR
87463(h)
Reappraisals
(h) The licensee shall request that all residents receive an annual routine visit with a licensed medical professional once every twelve months, either in person or by video appointment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on review of client records, the licensee did not comply with the section cited above in 1 out of 4 client records rviewed, which poses a potential health, safety or personal rights risk to persons in care.
- Medical assessment for client #1 is over 4 years old
POC Due Date: 07/07/2026
Plan of Correction
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Medical assessment for client #1 will be updated and copy will be sent to CCLD BY DUE DATE
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: 06/23/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/23/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/25/2026 10:14 AM - It Cannot Be Edited


Created By: Audrey Jeung On 06/23/2026 at 05:56 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: ANAMARIE CARE HOME LLC
FACILITY NUMBER: 415600983

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/23/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87507(c)
Admission Agreements
(c) Admission agreements shall be signed and dated, acknowledging the contents of the document, by the resident or the resident's representative, if any, and the licensee or the licensee's designated representative no later than seven days following admission. Attachments to the agreement may be utilized as long as they are also signed and dated as prescribed above.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on client records review, the licensee did not comply with the section cited above in 1 out of 4 records reviewed, which poses a potential health, safety or personal rights risk to persons in care.
- Admission agreement for client #2 is incomplete, as there is no monthly rate
POC Due Date: 07/07/2026
Plan of Correction
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2
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4
Copy of complete and signed admission agreement for client #2 to be sent to CCLD BY DUE DATE
Type B
Section Cited
CCR
87456(a)(2)
EVALUATION OF SUITABILITY FOR ADMISSION
Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8:

Perform a pre-admission appraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on review of client records, the licensee did not comply with the section cited above in 1 out of 4 records reviewed, which poses a potential health, safety or personal rights risk to persons in care.
- There is no pre admission appraisal for client #4, who was admitted 4 months ago.
POC Due Date: 07/07/2026
Plan of Correction
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2
3
4
Copy of complete and signed appraisal for client #4 will be sent to CCLD BY DUE DATE
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: 06/23/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/23/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/25/2026 10:14 AM - It Cannot Be Edited


Created By: Audrey Jeung On 06/24/2026 at 11:30 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: ANAMARIE CARE HOME LLC
FACILITY NUMBER: 415600983

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/23/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87468(b)(1)(A)
PERSONAL RIGHTS
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 the personal rights of residents specified in Sections 87468.1, Personal Rights of Residents in All Facilities or 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
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2
3
4
Based on review of client records, the licensee did not comply with the section cited above in 1 out of 4 records reviewed, which poses a potential health, safety or personal rights risk to persons in care.
- Personal Rights forms are incomplete or not maintained for clients #1, #3, #4
POC Due Date: 07/07/2026
Plan of Correction
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2
3
4
Copies of completed and signed Personal Rights forms for 3 clients will be sent to CCLD BY DUE DATE
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
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2
3
4
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: 06/24/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/24/2026


LIC809 (FAS) - (06/04)
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