415601063-11-6-2025-14-AS-JCAA-DN6VTC-20251106154255

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 415601063
Report Date: 11/06/2025
Date Signed: 11/06/2025 03:43:23 PM

Document Has Been Signed on 11/06/2025 03:43 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:	MISSION WOODSIDE		FACILITY NUMBER:	415601063
ADMINISTRATOR/ DIRECTOR:	GABRIELLA JOHNSON		FACILITY TYPE:	740
ADDRESS:	2028 MARYLAND STREET		TELEPHONE:	(650) 445-0510
CITY:	REDWOOD CITY	STATE: CA	ZIP CODE:	94061
CAPACITY: 6		CENSUS: 2	DATE:	11/06/2025
TYPE OF VISIT:	Case Management - Annual Continuation	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:00 AM
MET WITH:	Gabriella Johnson, Administrator, Tatiana Barsanti, Director of Quality and Anthony Lupian, Interim Senior Vice President of the South Care Region.		TIME VISIT/ INSPECTION COMPLETED:	03:45 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 11/6/2025, Licensing Program Analyst(LPA) John Calandra arrived at the facility to complete the Annual 1-year required inspection. LPA Calandra was greeted by Gabriella Johnson, Administrator and explained the purpose of the visit. Tatiana Barsanti, Director of Quality and Anthony Lupian, Interim Senior Vice President of the South Care Region arrived later during the visit. LPA toured the physical plant. This is a 1-story building with 6 bedrooms, 6 bathrooms, kitchen, living room, dining room, and back and front yards. All bedrooms had sufficient lighting and the required furniture. The bathroom had the required anti-skid floor mats and grab bars. Per interview with the Administrator the facility's fire alarms, smoke detectors, and Carbon Monoxide detectors are directly connected to the Redwood City Fire Department. Hot water temperature was measured within the required 105-120 degrees Fahrenheit. The facility's first aid kit had the required items. The facility had the required 7 days of non perishables and 2 days of perishables at the facility. No food was expired. All sharp objects, soap, detergent, poisons, and cleaning supplies were locked up and in-accessible to persons in care. LPA reviewed 1 resident file and 6 staff files. All staff files were observed to be complete but the resident file was missing Appraisal of Needs and Services. A review of Centrally stored medications indicated that medications for residents were properly labeled with instructions on dosage and times of day and matched the Centrally Stored Medication Records(CSMR) kept at the facility.

NAME OF LICENSING PROGRAM MANAGER: Brenda Chan
NAME OF LICENSING PROGRAM ANALYST: John Calandra
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 11/06/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2025

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: MISSION WOODSIDE	FACILITY NUMBER: 415601063
	VISIT DATE: 11/06/2025

NARRATIVE

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LPA received copies of the following documents while at the facility: Admission Policies and Procedures, Job Descriptions, Plan of Operation, Plan for Incidental Medical and Dental Care, Theft and Loss Policy and Transportation Procedures.

LPA requested the following documents be sent to the Department by 11/21/2025: LIC 500: Personnel Summary Report and Control of Property(Deed), Liability Insurance.

Deficiencies are cited under the California Code of Regulations, Title 22. Failure to correct the deficiencies by the due date may result in civil penalties.

An exit interview was conducted. This report was reviewed with facility representatives, and a copy of the report along with Appeal Rights left at the facility.

NAME OF LICENSING PROGRAM MANAGER: Brenda Chan
NAME OF LICENSING PROGRAM ANALYST: John Calandra
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 11/06/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/06/2025 03:43 PM - It Cannot Be Edited

Created By: John Calandra On 11/06/2025 at 03:09 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: MISSION WOODSIDE	FACILITY NUMBER: 415601063
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/06/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.695(e)(2)

Other Provisions

(e) A facility shall have all of the following information readily available to facility staff during an emergency: (2) An appraisal of resident needs and services plan for each resident. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not have an Appraisal of resident needs and services plan for each resident, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/21/2025
	Plan of Correction
1 2 3 4	Licensee will complete an Appraisal of Resident needs and services plan for each resident prior to admission of a resident. Licensee will send copies to the Department by the Plan of Correction(POC) due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 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.

	Brenda Chan
NAME OF LICENSING PROGRAM MANAGER:

	John Calandra
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/06/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2025

LIC809 (FAS) - (06/04)

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