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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 419210087
Report Date: 10/15/2024
Date Signed: 11/15/2024 12:18:48 PM

Document Has Been Signed on 11/15/2024 12:18 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:FLORA'S HOMEFACILITY NUMBER:
419210087
ADMINISTRATOR/
DIRECTOR:		ANCHETA, KELLYFACILITY TYPE:
735
ADDRESS:1008 CORTEZ AVENUETELEPHONE:
(650) 315-2242
CITY:BURLINGAMESTATE: CAZIP CODE:
94010
CAPACITY: 6CENSUS: 6DATE:
10/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Administrator, Kelly AnchetaTIME VISIT/
INSPECTION COMPLETED:
12:45 PM
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This is an Amended report from an Original dated report October 15, 2024.
Report amended to remove deficiency.


On October 15, 2024, Licensing Program Analyst (LPA), Murial Han conducted an unannounced annual inspection. LPA was greeted by the administrator, Kelly Ancheta and lead staff, Arvin Mariano. LPA explained the purpose of today's visit.

LPA toured the facility inside and outside including the bedrooms (2 shared and 2 private rooms), 2 full- bathrooms, 1 half bathroom, kitchen, living room, dinning room and common areas. The facility observed to clean, tidy and in good repair. Bedrooms and bathrooms were equipped with the required furniture for residents to use. Facility temperature is comfortable. Hot water temperatures in the kitchen and bathroom was measured at 105- 108 degrees F. Food supply is adequate for 2-day perishable and 7-day non-perishable.

Central stored medication, toxins and sharps objects were observed to be locked and inaccessible to residents.

Facility is equipped with smoke detectors and carbon monoxide detectors. Fire extinguishers were last inspected on 4/8/2024.

LPA reviewed P & I records for 6 residents to be adequate.

A review of (6) resident files was conducted and noted on the LIC 858.
A review of (6) staff files was conducted and noted on the LIC 859.

Today's inspection there is no residents present as they are attending the day program.

No deficiency cited today.

This report is reviewed and discussed with the administrator.

A copy of the report is provided.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE: DATE: 10/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/15/2024
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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Document Has Been Signed on 11/15/2024 12:19 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 11/13/2024 01:02 PM


Created By: Murial Han On 10/15/2024 at 12:06 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: FLORA'S HOME
FACILITY NUMBER: 419210087

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80069(a)(1)
80069 Client Medical Assessment (a) Except for licensees of ARFs , prior to or within 30 calendar days following the acceptance of a client,....(1) The assessment shall be performed by a licensed physician or designee, who is also a licensed professional, and the assessment shall not be more than one year old when obtained.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Deficiency RESCINDED.

POC Due Date: 10/22/2024
Plan of Correction
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Deficiency RESCINDED.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME:April Cowan
LICENSING EVALUATOR NAME:Murial Han
LICENSING EVALUATOR SIGNATURE:
DATE: 10/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/15/2024


LIC809 (FAS) - (06/04)
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