<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 419210087
Report Date: 10/29/2024
Date Signed: 10/29/2024 12:01:27 PM

Document Has Been Signed on 10/29/2024 12:01 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: 0DATE:
10/29/2024
TYPE OF VISIT:OfficeUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Administrator, Kelly AnchetaTIME VISIT/
INSPECTION COMPLETED:
12:00 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 October 29, 2024 San Bruno Regional Office- San Bruno Unit conducted a non-compliance conference office meeting.

Attendees included:

- Facility licensee/administrator Adora Ancheta
- Facility representative Kelly Ancheta
- Facility representative Rochelle Rivera
- GGRC Skylar Spencer
- CCLD Regional Manager Vivien Helbling
- CCLD Licensing Program Manager April Cowan
- CCLD Licensing Program Analyst Audrey Jeung
- CCLD Licensing Program Analyst
- CCLD Licensing Program Analyst

During the non-compliance meeting, the following serious violations were discussed: 80088(e)(1) Furniture, Fixtures, Equipment. and Supplies, 87407(e)(1-3) Administrator Recertification, 80026(h)(1) Safeguards for Cash Resources, Personal Property, and Valuables of Residents, 80077.3(a)- Care for Clients Who Lack Hazard Awareness or Impulse Control, and 80078(a) Responsibility for Providing Care and Supervision.

During this meeting, the compliance plan was developed and discussed with the licensee which includes more frequent monitoring inspection visits to ensure compliance with this compliance plan and Title 22 Regulations for 2 years. Licensee was provided the link below for resources and guidance to improve facility operations:

https://www.cdss.ca.gov/inforesources/community-care/resource-guide-for-providers.

In addition, Licensee was provided with an amended facility report of the annual inspection dated on 10/9/2023.

Furthermore, the Licensee was provided a case management report on LIC809, LIC809D and an LIC421IM form issuing an immediate civil penalty of $500. The immediate civil penalty of $500 was issued today due to absence of supervision that occurred on 5/10/2024 in which a Developmental Disable resident eloped from the facility without staff supervision.

This report was reviewed with the administrator and licensees and a copy of the report and appeal rights were provided.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE: DATE: 10/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/29/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1