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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 419210087
Report Date: 10/29/2024
Date Signed: 10/29/2024 11:59:59 AM

Document Has Been Signed on 10/29/2024 11:59 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: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:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Administrator, Kelly AnchetaTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
NARRATIVE
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On October 29, 2024, Licensing Program Analyst (LPA) Murial Han conducted an unannounced case management visit to follow up on an incident that was reported by the facility. LPA met with the administrator, Kelly Ancheta, the licensee Adora Ancheta and LPA explained the purpose of the visit.

On May 10, 2024, the facility reported resident #1 (R1) AWOL (Absent Without Official Leave), R1 was found by the local law enforcement at the neighbor's yard and R1 was escorted back to the facility by the officer.

On May 16, 2024, LPA conducted a case management visit and issued a deficiency under Title 22- 80077.3(a)- Care for Clients who Lack Hazard Awareness or Impulse Control.

During today's meeting, an additional deficiency is issued as the licensee did not provide care and supervision as necessary to meet the needs of the resident resulted resident #1 (R1) left the facility unattended and staff did know R1 was missing until R1 was escorted back to the facility by the local law officer.

Due to the above observation, an immediate civil penalty is being assessed today in the amount of $500 for Absence of Supervision.

Deficiency is cited under California Code of Regulations, Title, 22 cited on the LIC 809D.
Failure to correct the deficiencies may result in additional civil penalties.

This report is reviewed and discussed with the administrator and the licensee. A copy of this report and the 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)
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Document Has Been Signed on 10/29/2024 11:59 AM - It Cannot Be Edited


Created By: Murial Han On 10/28/2024 at 03:57 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: FLORA'S HOME
FACILITY NUMBER: 419210087

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/29/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/30/2024
Section Cited
CCR
80078(a)

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80078 Responsibility for Providing Care and Supervision(a) The licensee shall provide care and supervision as necessary to meet the client's needs. This requirement is not met as evidenced by:
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The Licensee/administrator will develop a plan to ensure facility has sufficient staff to care and supervise residents at all times. The plan shall include staff training. The Licensee/administrator will provide a copy of the plan to CCL by 10/30/2024.
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Based on observation, and interview resident #1 (R1) left the facility unattended and staff did not know R1 was missing until R1 was escorted by the local law officer which poses an immediate health and safety risk to residents in care.
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An Immediate Civil Penalty in the amount of $500 is being assessed today.

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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: 10/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/28/2024


LIC809 (FAS) - (06/04)
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