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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 419200005
Report Date: 10/14/2023
Date Signed: 10/14/2023 02:30:31 PM

Document Has Been Signed on 10/14/2023 02:30 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:ALBRIGHT HOMEFACILITY NUMBER:
419200005
ADMINISTRATOR:ANCHETA, KERSTENFACILITY TYPE:
735
ADDRESS:2501 ALBRIGHT WAYTELEPHONE:
(650) 588-2962
CITY:SOUTH SAN FRANCISCOSTATE: CAZIP CODE:
94080
CAPACITY: 6CENSUS: 4DATE:
10/14/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Kelly AnchetaTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to conduct a Required - 1 Year visit on 10/14/23 at 12:00PM. LPA met with Edmund Picardo, Caregiver who contacted the Administrator Kersten Ancheta regarding todays visit. Kelly Ancheta called facility to state she will arrive to assist with todays visit. The facility is licensed for a capacity of 6 non-ambulatory residents of which wheelchair bound residents are allowed in room 4.

The Administrator Certificate for Kelly Ancheta was observed expired 5/18/23. LPA observed documentation of payment and hours for renewal dated 10/10/23 that has been submitted to Community Care Licensing (CCL). The late submission was cited on 10/9/23 at another facility for this Administrator which has been cleared. LPA observed P&I monies for Resident #1 (R1) which has been counted and documented properly and not commingled during this visit. Upon arrival 3 residents were out in the community with staff. On arrival back to the facility the residents had lunch. LPA toured and inspected the physical plant inside and outside to ensure there are no safety hazards to residents. LPA observed 2-day perishables and 7-day non-perishables. The temperature inside the facility was observed to be at 74*F which is within the required range of 68-85*F. The hot water temperature was measured at 110.3*F which is within the required range of 105-120*F. LPA observed fire extinguisher(s), pull alarm system, smoke and carbon monoxide detectors in the facility.
Last emergency drill was conducted on 5/2/23. LPA observed the centrally stored medications area to be locked and inaccessible to residents. The first aid kit contained the required items such as sterile dressings, bandages, adhesive tape, scissors, tweezers, thermometers, antiseptic solution and guide.

LPA observed 1 staff files and 2 resident files and conducted interviews during this visit.
Upon a file review the following items were discussed to be submitted with any changes annually:
Any addendums for the Infection Control Plan, Designation of Facility Responsibility (LIC308), Personnel Report (LIC500) to include the Administrator presence in the facility, Administrator Certificate-Updated, Affidavit Regarding Client/Resident Cash Resources (LIC400), Surety Bond (LIC402), Control of Property, Emergency Disaster Plan (LIC610D) .

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 6, no deficiencies are being cited. An exit interview was conducted, a copy of the report was given.
SUPERVISORS NAME: Victoria Brown
LICENSING EVALUATOR NAME: Victoria Brown
LICENSING EVALUATOR SIGNATURE: DATE: 10/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/14/2023
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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