George Anne Home
RCFE · Memory Care
A Residential Care Facility for the Elderly (RCFE) is a non-medical residential care home licensed by California CDSS under Health & Safety Code §1560. Residents receive help with daily living activities such as bathing, dressing, and medication management. An RCFE with a Memory Care designation is additionally required by California Title 22 (§87705 and §87706) to provide specialized staff training in dementia care, individualized care plans for residents with cognitive impairment, and appropriate supervision protocols — requirements that go beyond a standard RCFE license.
849 N Delaware Street · San Mateo, 94401
Quick facts
Quality snapshot
Updated April 26, 2026Compared to 182 California RCFE memory care facilities of similar size, over the last 36 months.
Source: California Department of Social Services, Community Care Licensing Division. View raw inspection records →
Quality grade· click to show how this was calculated
Severity1thWeighted citations per bed
Repeats100thRepeat deficiencies as share of total
Frequency12thDeficiencies per inspection
Tick mark at 50% = peer median · higher percentile = better facility
Quality grade· click to show how this was calculated
Weighted citations per bed
Repeat deficiencies as share of total
Deficiencies per inspection
Tick mark at 50% = peer median · higher percentile = better facility
George Anne Home scores D. Better than 38% of comparable California RESIDENTIAL CARE ELDERLY facilities. Severity: bottom 1%. Repeats: top 0%. Frequency: bottom 12%.
Each metric is converted to a 0–100 percentile within the peer set (higher = better). The composite grade averages all four. Peer set: CA / rcfe_memory_care / small beds (182 facilities).
Citation severity over time
↓ improvingWeighted severity score per month · 24 months
Weighted score (24mo)
188
Last citation
Aug 25
Finding distribution
49 total · 36 monthsScope × Severity (CMS A–L)
The rules that apply to this facility
California Title 22 requirements for this facility, with the specific regulation and a suggested question for each.Rules this facility has been cited for are shown first.
What dementia-care training must staff complete?Cited Sep 202422 CCR §87705 / HSC §1569.625
Because this facility markets dementia or Alzheimer's care, state law mandates higher training standards:
- 12 hours initial dementia training — 6 hours before a staff member works independently with residents, 6 more within the first 4 weeks.
- 8 hours annual dementia in-service — required every year thereafter.
- Administrator CE — the administrator must include 8 hours of dementia-specific continuing education in every 2-year recertification cycle.
Training must cover individualized care plans, behavioral expressions, appropriate supervision, and the facility's dementia care philosophy.
Ask on tour: Ask how dementia training records are kept — families may request documentation.
How many staff must be on duty overnight?22 CCR §87415
Based on 6 licensed beds:
One qualified staff member must be on call and physically on premises at all times overnight.
Violation pattern to watch for:A facility that documents a staff member as "on call" but with that person physically off-site — when the law requires on-premises presence — is in violation of this section.
Ask on tour: Ask the facility to walk you through their overnight staffing plan and confirm whether on-call staff are on premises or off-site.
What health conditions can this facility legally accept or refuse?22 CCR §87612–87615
Restricted — allowed with physician order + care plan
- Supplemental oxygen
- Insulin and injectable medications
- Indwelling or intermittent catheters
- Colostomy / ileostomy
- Stage 1 and Stage 2 pressure injuries
- Wound care (non-complex)
- Incontinence
- Contractures
Prohibited — facility must refuse or discharge
- Stage 3 or Stage 4 pressure injuries
- Feeding tubes (PEG, NG, or J-tube)
- Tracheostomies
- Active MRSA or communicable infections requiring isolation
- 24-hour skilled nursing needs
- Total ADL dependence with inability to communicate needs
A hospice waiver (HSC §1569.73) can allow continued care for residents on hospice who would otherwise fall into a prohibited category.
Ask on tour: Ask whether your loved one's specific care needs are restricted or prohibited, and what the facility's process is if needs change after admission.
What must this facility report to the state — and how fast?22 CCR §87211 / WIC §15630
- ImmediateElopement, fire, epidemic outbreak, or poisoningImmediately
- 2 hoursAbuse with serious bodily injury2-hour phone report + 2-hour written report — to the California Department of Social Services (CDSS), Adult Protective Services, and law enforcement
- 24 hrsAbuse without serious bodily injuryWithin 24 hours
- Next dayDeath of a residentPhone by next working day; written within 7 days
- Next dayInjury requiring medical treatment beyond first aidPhone by next working day; written within 7 days
- WrittenBankruptcy, foreclosure, eviction, or utility shutoff noticeWritten notice to CDSS and residents — $100/day penalty (max $2,000) for failure
Your enforcement lever:Incidents that aren't reported on time are themselves a separate violation. If you believe a reportable event wasn't filed, you can submit a complaint directly to the California Department of Social Services (CDSS).
How does CDSS enforce these rules?22 CCR §87755–87777 / HSC §1569.58
- 1Notice of DeficiencyWritten citation with a correction deadline. Facility must submit a Plan of Correction.
- 2Civil PenaltyStarts at $50/day for non-serious; $150/day for serious deficiencies — immediately, with no grace period. Repeats escalate to $150 first day + $50/day, then $1,000 first day + $100/day.
- 3Suspension of AdmissionsFacility cannot accept new residents until violations are corrected.
- 4Temporary Suspension or RevocationEmergency suspension for imminent danger; full revocation after administrative hearing.
- 5Exclusion OrderAdministrator and operator can be barred from all CDSS-licensed facilities — not just this one.
See how these rules have been applied to this specific facility:
View state inspection record and citationsState records
California Dept. of Social Services · Community Care Licensing- License number
- 415600966
- License type
- RESIDENTIAL CARE ELDERLY
- License status
- LICENSED
- License expires
- Not yet indexed
- Licensed beds
- 6
- Operator
- Gong, Peter
Inspections & citations
12
reports on file
49
total deficiencies
12
Type A (actual harm)
2
dementia-care citations
Other visitJanuary 13, 2026No deficiencies
Plain-language summary
The facility had an informal meeting with state licensing staff to discuss an ownership change, outstanding deficiencies from inspections in July and August 2025, and whether the administrator meets qualifications. The owner agreed to submit written plans showing how the facility will fix these deficiencies within ten days.
View full inspector notes
An informal meeting was convened in the San Bruno regional office today. In attendance are: - Licensee Peter Gong - Licensing Program Manager April Cowan - Licensing Program Analyst Audrey Jeung - Licensing Program Analyst Murial Han - Licensing Program Analyst Grace Donato The following concerns are discussed: - Ownership change from individual proprietorship to Limited Liability Corporation - Plans of Correction of deficiencies cited during annual visit 7/31/25 and subsequent case management visits - Administrator qualifications Outstanding deficiencies cited on 8/27/25 are identified and a copy of Facility Evaluation Report is given to licensee. Mr. Gong agreed to submit plans/proof of corrections to CCLD within TEN DAYS. Licensee will also create and implement a plan to address the above concerns; written plan to be submitted to CCLD within TEN DAYS.
Other visitAugust 27, 2025Type A9 deficiencies
Plain-language summary
This was a follow-up inspection to check whether problems found in July and August 2025 had been fixed. The facility has not yet corrected all the deficiencies from those earlier inspections, and the state is now referring the facility to a technical assistance program to help them address the remaining issues.
View full inspector notes
To follow up on deficiencies cited on 7/31/25, 8/5/25 and 8/14/25, LPA Jeung met with administrator and licensee to review documents submitted as corrections. Deficiencies not yet corrected are being recited, as per California Code of Regulations, Title 22, and appear on following pages. Licensee agreed to avail of Technical Support Program assistance. LPA to make referral to TSP, and licensee will be contacted by TSP staff to arrange for consultation.
Regulation
PERSONAL RIGHTS Residents in all RCFEs shall have... the ... personal right to be accorded safe, healthful &comfortable accommodations, furnishings & equipment. This requirement is not met, as client in room #5 is observed in bed with recliner chair & wheelchair placed next to
Inspector finding
bed, preventing her from getting out of bed. Licensee failed to ensure that clients are accorded safe & healthful accommodations, which poses an immediate health, safety or personal rights risk to clients in care. This was cited on 8/5/25, and "explanation" was submitted on 8/6/25, not correction.
Regulation
FALSE CLAIMS No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility... This requirement was not met, as facility staff obtained personal and confidential information by falsely stating that the
Inspector finding
information was required by state licensing. Licensee failed to prevent staff from making false claims, which poses an immediate health, safety or personal rights risk to clients in care. This was cited on 8/14/25 and not addressed in plan of correction submitted on 8/18/25.
Regulation
PRE-ADMISSION APPRAISAL Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of their individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance/Retention LimitS.
Inspector finding
This requirement is not met, as there is no signed appraisal on file for client #5, who was admitted 3 years ago. This poses a potential health, safety or personal rights risk to clients. This was cited on 9/3/24 and 7/31/25.
Regulation
REAPPRAISALS The pre-admission appraisal... shall be updated in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition... and to keep the appraisal accurate. This requirement is not met as
Inspector finding
reappraisals for ALL clients are missing or dated more than 12 months ago. Licensee failed to ensure that annual reappraisals are done, which poses a potential health, safety or personal rights risk to clients. This deficiency was observed on 9/3/24 & 7/31/25, & proof of correction was not submitted.
Regulation
GENL REQUIREMNTS HEALTH COND. The licensee shall complete & maintain a current, written record of care... that includes, but is not limited to... Documentation from the physician of... Stability of the medical condition, Medical condition which requires incidental medical services, Method of
Inspector finding
intervention...skilled professional...who will perform the procedure if the resident needs assistance; names...phone number of...skilled professionals providing services, Emergency contacts. Client #4 has gall bladder stoma & there is no info about care or condition. This was cited on 7/31/25.
Regulation
INCIDENTAL MEDICAL CARE All centrally stored medications shall be labeled and maintained in compliance with state and federal laws. No persons other than the dispensing pharmacist shall alter a prescription label. This requirement is not met, as staff write on RX labels. Licensee
Inspector finding
failed to ensure that staff do not write on Rx labels, which poses a potential health, safety or personal rights risk to clients in care. This was cited on 8/5/25 and not corrected.
Regulation
INCIDENTAL MEDICAL CARE Rx medications which are not taken with the resident upon termination of services, not returned to the issuing pharmacy, nor retained in the facility as ordered by the resident’s physician & documented in the resident’s record nor disposed of... shall be destroyed in the facility by the facility
Inspector finding
administrator & another adult who is not a resident. Both shall sign a record, to be retained for at least 3 years, which lists... specific information. This requirement is not met, as Rx meds for former client observed in kitchen cabinet, which poses a potential health, safety or personal rights risk. This was cited 8/5/25.
Regulation
PERSONAL RIGHTS Residents in all RCFEs shall have the personal right to have access to individual storage space for private use. This requirement is not met, as facility records are stored in client room #4. Licensee failed to ensure that client's room is for client's
Inspector finding
personal use and not used by staff. This poses a potential health, safety or personal rights risk to clients in care. This was cited on 8/5/25 and not corrected
Regulation
INCIDENTAL MEDICAL CARE For every Rx and non Rx medication for which the licensee provides assistance there shall be a signed, dated written order from a physician, on a prescription blank, maintained in the residents file, and a label on the medication. Both the MD order & the
Inspector finding
label shall contain ...specific information. This requirement is not met, as MD orders are not maintained for C3 OTC Senna and C6 Senna Plus. Licensee failed to ensure that MD orders are maintained for OTC meds, which poses a potential health, safety or personal rights risk. This was cited 8/5/25.
Other visitAugust 14, 2025No deficiencies
Plain-language summary
This was a follow-up inspection on August 13, 2025, to check whether the facility had corrected violations found in late July and early August. The facility corrected five violations including updating a resident's medical status, obtaining bed rail orders, submitting emergency contact information, providing staff first-aid training, and having a first-aid manual on site; a $700 civil penalty was assessed for the period when one violation remained uncorrected. However, multiple other violations remained unfixed, including incomplete admission paperwork signed by residents or their representatives, missing health screenings for staff, and failure to document that residents have the right not to be confined to bed, and the facility was advised that additional penalties may result if these are not corrected by the deadline.
View full inspector notes
To follow up on deficiencies cited on 7/31/25--for which civil penalty of $100 accrued daily for one deficiency starting on 8/5/25--and 8/5/25, LPA Jeung reviewed corrections that were submitted to licensing office on 8/13/25. The following deficiencies are corrected, and acknowledgement of corrections is issued--5 pages: - Section 87204 Limitations - Capacity & Ambulatory Status Updated MD report for Client #1 states that client is Non-ambulatory Civil penalty of $700 is assessed today, which represents civil penalty of $100/day for period 8/6/25 through and including 8/12/25. See LIC421FC. - Section 87608 Postural Supports MD orders for half bed rails for clients #1, #3, #5, #6 were sent to CCLD - Section 87506 Resident Records Emergency information for clients #1, #2, #4 were sent to CCLD - Section 87411 Personnel Requirements Proof of current first-aid training for staff #2, #3, #4, #5, #6 sent to CCLD - 87465 Incidental Medical Care First-aid manual is observed at facility Continued on next page 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 26 27 28 29 30 31 32 The following deficiencies cited on 7/31/25 still exist, as plan of corrections was not submitted to CCLD: - CCR 87457(c) Pre-Admission Appraisal Appraisal for client #5 will be completed, signed and dated BY CLIENT OR REPRESENTATIVE AND FACILITY REPRESENTATIVE - Health and Safety Code 1569.695(b) - Health and Safety Code 1569.695(c) - 87463(a) Reappraisals Appraisals for all clients will be completed, signed and dated BY CLIENT OR REPRESENTATIVE AND FACILITY REPRESENTATIVE - CCR 87611(b)(1-3) General Requirements for Allowable Health Conditions - CCR 87412(a)(1-13) Personnel Records The following deficiencies cited on 8/5/25 still exist, as plan of corrections was not submitted to CCLD: - CCR 87468.1(a)(1) Personal Rights "Explanation" was submitted, but affirmation that clients have the right to NOT be confined in bed was NOT submitted - Health and Safety Code 1569.69(a) - Health and Safety Code 1569.626(a) - Health and Safety Code 1569.696(a) - CCR 87411(f) Health screenings were not submitted for 6 staff - CCR87618(b)(1)(B) - CCR 87465(h)(1)(4) - CCR 87468.1(a)(13) - CCR 87465(i)(1-4) - CCR 87465(e)(1-4) Administrator Maria Johnson is advised that failure to correct the cited deficiencies on or before the Plan of Correction due date may result in a civil penalty assessment. As per phone conversation, additional time is needed to submit corrections. Written request shall be submitted to CCLD by close of business TODAY, with requested revised due date.
Other visitAugust 14, 2025Type A2 deficiencies
Plain-language summary
A case management visit was conducted after concerns were raised during a phone call with a resident's family member, and violations of California regulations were found. The specific violations are documented in the inspection report. No additional details about the nature of the violations are provided in this summary section.
View full inspector notes
In response to information obtained during phone call with a resident's responsible party, LPA Jeung initiated this case management visit, as deficiencies of the California Code of Regulations, Title 22 occurred. Citations are documented on following pages.
Regulation
FALSE CLAIMS No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility... This requirement was not met, as facility staff obtained personal and confidential information by falsely stating that the
Inspector finding
information was required by state licensing. Licensee failed to prevent staff from making false claims, which poses an immediate health, safety or personal rights risk to clients in care.
Regulation
RESIDENT RECORDS All information & records obtained from or regarding residents shall be confidential. The licensee shall be responsible for storing...records & for safeguarding the confidentiality of their contents. The licensee & all employees shall reveal or make available confidential
Inspector finding
information only upon the resident's written consent or... designated representative. This requirement was not met, as staff shared unsolicited personal and confidential client information via text to another client's responsible party. Licensee failed to ensure the confidentiality of client information, which poses an immediate health, safety or personal rights risk to clients in care.
InspectionAugust 5, 2025No deficiencies
Plain-language summary
This was a follow-up inspection on April 26, 2026 to check on problems found during an annual inspection in July 2025. The facility fixed one issue—its administrator now has the required certificate—but has not resolved another: a resident who is bedridden is living at the facility, which is not licensed to care for bedridden residents. The state is imposing a $100 daily penalty until the facility addresses this violation.
View full inspector notes
To follow up on deficiencies cited during annual inspection on 7/31/25, LPA Jeung reviewed deficiencies, which were to be corrected by 8/4/25. The following deficiency is corrected: - Section 87405 Administrator Qualifications & Duties As per information on CCLD Administrator Certification website, Ms. Johnson has current RCFE administrator certificate Acknowledgement of correction is provided--one page. The following deficiency still exists: - Section 87204 Limitations - Capacity & Ambulatory Status Client #1 is deemed to be bedridden per MD, and facility is not licensed to serve bedridden clients Civil penalty of $100 is assessed today and will continue to accrue at $100/day until CCLD is notified of correction. See LIC421FC.
InspectionAugust 5, 2025Type A6 deficiencies
Plain-language summary
During the annual inspection in July 2025, reviewers found that staff training records were not available for inspection and identified multiple violations of state regulations regarding medication storage and record-keeping. The facility was referred to a state technical support program to help them meet regulatory requirements. Reviewers will help facilitate additional training assistance if the facility requests it.
View full inspector notes
To complete annual inspection of 7/31/25, LPA Jeung reviewed Centrally Stored Medications Records and staff training records. However, training records are not available to review. Deficiencies of the California Code of Regulations, Title 22, are cited on following pages. Due to multiple and repeated deficiencies cited, information about the CCLD Technical Support Program is recommended and provided to administrator, to provide assistance and training in meeting regulatory requirements. LPA will facilitate referral to TSP assistance upon request from facility.
Regulation
OXYGEN ADMINISTRATION ..."No Smoking-Oxygen in Use" signs shall be posted in the appropriate areas. This requirement was not met, as there were no oxygen in use signs posted on 7/31/25 during initial annual inspection, which poses a potential health, safety or personal rights risk.
Regulation
INCIDENTAL MEDICAL CARE All centrally stored medications shall be labeled and maintained in compliance with state and federal laws. No persons other than the dispensing pharmacist shall alter a prescription label. This requirement is not met, as staff write on RX labels. Licensee
Inspector finding
failed to ensure that staff do not write on Rx labels, which poses a potential health, safety or personal rights risk to clients in care.
Regulation
PERSONAL RIGHTS Residents in all RCFEs shall have... the ... personal right to be accorded safe, healthful &comfortable accommodations, furnishings & equipment. This requirement is not met, as client in room #5 is observed in bed with recliner chair
Inspector finding
and wheelchair placed next to bed, preventing her from getting out of bed. Licensee failed to ensure that clients are accorded safe & healthful accommodations, which poses an immediate health, safety or personal rights risk to clients in care.
Regulation
PERSONAL RIGHTS Residents in all RCFEs shall have the personal right to have access to individual storage space for private use. This requirement is not met, as facility records are stored in client room #4. Licensee failed to ensure that client's
Inspector finding
room is for client's personal use and not used by staff. This poses a potential health, safety or personal rights risk to clients in care.
Regulation
INCIDENTAL MEDICAL CARE Rx medications which are not taken with the resident upon termination of services, not returned to the issuing pharmacy, nor retained in the facility as ordered by the resident’s physician & documented in the resident’s record nor disposed of... shall be destroyed in the facility by the facility
Inspector finding
administrator & another adult who is not a resident. Both shall sign a record, to be retained for at least 3 years, which lists... specific information. This requirement is not met, as Rx meds for former client observed in kitchen cabinet, which poses a potential health, safety or personal rights risk.
Regulation
INCIDENTAL MEDICAL CARE For every Rx and non Rx medication for which the licensee provides assistance there shall be a signed, dated written order from a physician, on a prescription blank, maintained in the residents file, and a label on the medication. Both the
Inspector finding
physician's order and the label shall contain ...specific information. This requirement is not met, as MD orders are not maintained for C3 OTC Senna and C6 Senna Plus. Licensee failed to ensure that MD orders are maintained for OTC meds, which poses a potential health, safety or personal rights risk
Other visitJuly 31, 2025Type B11 deficiencies
Plain-language summary
An inspector visited the facility to evaluate its physical space and operations, finding six private bedrooms, adequate bathrooms, sufficient lighting and temperature control, working carbon monoxide detectors, and a safe outdoor area with no water hazards or fire risks. The facility was asked to provide updated documentation on emergency planning, staff medication training, insurance, and personnel records by August 7, 2025, and state regulators noted that the facility administrator does not hold the required certification. Staff training will be reviewed in a follow-up visit.
View full inspector notes
LPA Audrey Jeung toured facility and grounds, consisting of 6 private client bedrooms, 3 full bathrooms, kitchen/living/dining room. There is a detached staff unit/building that contains a bedroom with one bed, a large room with 2 bunk beds, kitchen, and full bathroom for staff. Awake night staff is employed. Two additional detached storage sheds are in the backyard, and washer and dryer are located in an alcove adjacent to staff unit/building. The spacious backyard is level, paved and landscaped, with 2 gazebos. There are no accessible bodies of water or fire safety hazards observed. A comfortable room temperature is maintained, and lighting is sufficient for safety. Carbon monoxide detectors are present and tested as operable. First-aid kit is maintained. Medications are stored in hall and kitchen cabinets. Client and staff records are reviewed. Maria Lu Johnson oversees facility operations, but does not have valid RCFE administrator certification. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed. A Disaster and Mass Casualty Plan is posted. The following forms/information are requested to be updated returned to CCL by 8/7/25: • LIC 610 Emergency Disaster Plan (page 9, signed and dated) • Staff medication TRAINING topics (per H & S 1569.69) • LIC 308 Designation of Facility Responsibility • LIC 500 Personnel Report • Proof of current liability insurance Deficiencies of the CA Code of Regulations, Title 22 are cited on following pages. Staff training will be reviewed at a later date, due to time constraints.
Regulation
LIMITATIONS - CAPACITY & AMBULATORY STATUS A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including specification of the maximum number of persons who may receive services at any one time.
Inspector finding
This requirement is not met, as client #1 is determined by MD to be bedridden, but facility is not licensed for bedridden clients. Licensee failed to ensure operation within limits of license, which poses a potential health, safety or personal rights risk to clients in care.
Regulation
PRE-ADMISSION APPRAISAL Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of their individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance/Retention LimitS.
Inspector finding
This requirement is not met, as there is no signed appraisal on file for client #5, who was admitted 3 years ago. This poses a potential health, safety or personal rights risk to clients. This was cited on 9/3/24.
Regulation
POSTURAL SUPPORTS A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. This requirement is not met, as there are no MD orders maintained for 4 out of 6 clients who have half bed rails. Licensee failed to
Inspector finding
maintain MD orders for use of half bed rails, which poses a potential health, safety or personal rights risk to clients in care. This deficiency was cited on 9/3/24 and proof of correction was not submitted.
Regulation
REAPPRAISALS The licensee shall request that all residents receive an annual routine visit with a licensed medical professional... every 12 months...Documentation.. shall be added to the resident's record...of a resident's refusal...shall be added to the resident's record. This requirement is not
Inspector finding
met, as MD assessments for 3 out of 6 client were done over 3 years ago or not maintained. Licensee failed to ensure annual MD assessments, which poses a potential health, safety or personal rights risk. NO MD report for C2, MD reports for C5 & C6 dated 2022. This deficiency observed 9/3/24.
Regulation
REAPPRAISALS The pre-admission appraisal... shall be updated in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition... and to keep the appraisal accurate. This requirement is not met as
Inspector finding
reappraisals for ALL clients are missing or dated more than 12 months ago. Licensee failed to ensure that annual reappraisals are done, which poses a potential health, safety or personal rights risk to clients. This deficiency was observed on 9/3/24 and proof of correction was not submitted.
Regulation
RESIDENT RECORDS Each resident’s record shall contain…Resident's legal name…Social Security number, Date of admission…Last known address, Birthdate, Religious preference, if any…Names, address, and telephone numbers of the resident’s representative … to be notified in case of emergency,
Inspector finding
Name, address, phone number of physician and dentist to be called in an emergency. This requirement is not met, as there is no emergency informatiion maintained for 3 out of 6 clients, which poses a potential health, safety or personal rights risk. No emergency info for C1, C2, C4
Regulation
GENL REQUIREMNTS HEALTH COND. The licensee shall complete & maintain a current, written record of care... that includes, but is not limited to... Documentation from the physician of... Stability of the medical condition, Medical condition which requires incidental medical services, Method of
Inspector finding
intervention...skilled professional...who will perform the procedure if the resident needs assistance; names...phone number of...skilled professionals providing services, Emergency contacts. Client #4 has gall bladder stoma & there is no information about care or condition.
Regulation
ADMIN QUALIFICATIONS DUTIES All facilities shall have a qualified and currently certified administrator. This requirement is not met, as proof of a certified RCFE administrator is not available. Licensee failed to ensure there is a certified RCFE administrator, which poses a
Inspector finding
potential health, safety or personal rights risk to clients in care.
Regulation
PERSONNEL RECORDS The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain specific information. This requirement is not met, as staff records for 6 out of 6 files reviewed are
Inspector finding
missing job applications, health screenings, including TB test results, criminal record statements. Licensee failed to ensure required staff records are maintained, which poses a potential health, safety or personal rights risk to clients. This was observed on 9/3/24 and not corrected.
Regulation
PERSONNEL REQUIREMENTS Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met, as 5 out of 6 staff do not have proof of current first aid training, which poses a potential
Inspector finding
health, safety or personal rights risk to clients in care.
Regulation
INCIDENTAL MEDICAL CARE ... a complete first aid kit shall be maintained and be readily available in a specific location in the facility. The kit shall be...approved by the American Red Cross, or shall contain at least... current edition of a first aid manual approved by
Inspector finding
the American Red Cross, the American Medical Association or a state or federal health agency. This requirement is not met, as there is no first-aid manual available, which poses a potential health, safety or personal rights risk to clients in care.
Other visitSeptember 3, 2024Type A16 deficiencies
Inspector: Audrey Jeung
Plain-language summary
This was a routine facility tour that found the six-bedroom home is well-maintained with appropriate staffing, safety equipment, and record-keeping in place. The inspector identified two minor documentation updates needed: a signed emergency plan and written staff medication training procedures. No violations of care standards were found.
View full inspector notes
LPA Audrey Jeung toured facility and grounds, consisting of 6 private client bedrooms, 3 full bathrooms, kitchen/living/dining room. There is a detached staff unit/building that contains a bedroom with one bed, a large room with 2 bunk beds, kitchen, and full bathroom for staff. Awake night staff is employed. Two additional detached storage sheds are in the backyard, and washer and dryer are located in an alcove adjacent to staff unit/building. The spacious backyard is level, paved and landscaped, with 2 gazebos.. There are no accessible bodies of water or fire safety hazards observed. A comfortable room temperature is maintained, and lighting is sufficient for safety. Carbon monoxide detector is tested and operable. First-aid kit is maintained and complete. Medications are stored in hall and kitchen cabinets, and Centrally Stored Medications Records are maintained. Client and staff records are reviewed. A Disaster and Mass Casualty Plan is posted. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed. Maria Lu Johnson is a certified RCFE administrator that oversees facility operations. The following forms/information are requested to be updated returned to CCL by 9/17/24: • LIC 610 Emergency Disaster Plan (page 9, signed and dated) • Staff medication training policy (per H & S 1569.69) Deficiencies of the CA Code of Regulations, Title 22 are cited on following pages. See also Technical Advisory Notes--4 pages.
Regulation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degre…
Inspector finding
Based on observation, the licensee did not comply with the section cited above, as hot water temperature tested at 128 degrees in rear common bathroom. This poses an immediate health, safety or personal rights risk to persons in care. POC Due Date: 09/04/2024 Plan of Correction 1 2 3 4 Hot water temperature to be lowered and maintained between 105 and 120 degrees at all times. Proof of correction to be sent to CCLD BY DUE DATE. This deficiency was cited during annual inspection in 2023.
Regulation
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.
Inspector finding
Based on observation, the licensee did not comply with the section cited above, as cleaning liquids are stored where accessible to clients. In bathroom in room #1 and common bathroom, purple liquid Fabuloso is stored. Pine Sol, degreaser, and other cleaning liquids are stored in unlocked cabinet under kitchen sink, and gallon of Clorox bleach observed in backyard in gazebo. This poses an immediate health, safety or personal rights risk to persons in care. POC Due Date: 09/04/2024 Plan of Co…
Regulation
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.
Inspector finding
Based on observation, the licensee did not comply with the section cited above, as clients' medications are stored in unlocked cabinets in hallway and kitchen, which poses an immediate health, safety or personal rights risk to persons in care. POC Due Date: 09/04/2024 Plan of Correction 1 2 3 4 Clients' medications will be stored where they are inaccessible to residents. Proof of correction to be sent to CCLD BY DUE DATE. This deficiency was cited during annual inspection in 2023.
Regulation
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after e…
Inspector finding
Based on staff records review, the licensee did not comply with the section cited above in 3 out of 6 staff files reviewed, which poses a potential health, safety or personal rights risk to persons in care. There is no health screening and TB test result for staff #2 and #3. Staff #1 has no health screening on file. POC Due Date: 09/17/2024 Plan of Correction 1 2 3 4 Health screenings and/or TB test results for staff #1, #2, #3 to be sent to CCLD BY DUE DATE
Regulation
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivisi…
Inspector finding
Citation deleted POC Due Date: 09/17/2024 Plan of Correction 1 2 3 4 NA
Regulation
(a) All residential care facilities for the elderly shall provide training to direct care staff on postural supports, restricted conditions or health services, and hospice care as a component of the training requirements specified in Section 1569.625. The training shall include all of the following:
Inspector finding
Based on staff records review, the licensee did not comply with the section cited above, as there is no documentation that staff received 4 hours of training on postural supports, restricted health conditions, and hospice care. This poses a potential health, safety or personal rights risk to persons in care. POC Due Date: 09/17/2024 Plan of Correction 1 2 3 4 Staff will receive required 4 hours of training as specified, and proof of training to be sent to CCLD BY DUE DATE.
Regulation
(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements:
Inspector finding
Based on staff records review, the licensee did not comply with the section cited above, as there is no documentation that staff who handle or manage medications have received required medications training. This poses a potential health, safety or personal rights risk to persons in care. POC Due Date: 09/17/2024 Plan of Correction 1 2 3 4 Staff who handle medications shall receive required medications training, and proof of training to be sent to CCLD BY DUE DATE. This shall include 10 hours …
Regulation
(b) At the time the admission agreement is signed, a resident and the resident's representative shall be personally advised of and given a copy of: (1) The personal rights of residents specified in Sections 87468.1, Personal Rights of Residents in All Facilities and 87468.2, Additional Personal Rights of Residents in Privately Operated Facilities,…
Inspector finding
Based on client records review, the licensee did not comply with the section cited above in 2 out of 6 client files reviewd, which poses a potential health, safety or personal rights risk to persons in care. Personal rights forms are incomplete or missing for clients #1 and #2. POC Due Date: 09/17/2024 Plan of Correction 1 2 3 4 Personal Rights forms shall be completed, signed, and dated for clients #1 and #2. Copies will be sent to CCLD BY DUE DATE.
Regulation
(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations.
Inspector finding
Based on client records review, the licensee did not comply with the section cited above in 1 out of 6 client files reviewed, which poses a potential health, safety or personal rights risk to persons in care. There is no appraisal on file for client #5, who was admitted over 2 years ago. POC Due Date: 09/17/2024 Plan of Correction 1 2 3 4 Appraisal for client #5 will be completed, signed and dated, and copy will be sent to CCLD BY DUE DATE.
Regulation
(b) A facility shall provide training on the plan to each staff member upon hire and annually thereafter. The training shall include staff responsibilities during an emergency or disaster.
Inspector finding
Based on staff records review, the licensee did not comply with the section cited above, as staff have not received training on responding to emergencies. This poses a potential health, safety or personal rights risk to persons in care. POC Due Date: 09/17/2024 Plan of Correction 1 2 3 4 Staff shall receive emergency response training, and proof of correction to be sent to CCLD BY DUE DATE
Regulation
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill,…
Inspector finding
Based on absence of documentation and confirmation from staff, the licensee did not comply with the section cited above, as there is no documentation that of emergency drills. This poses a potential health, safety or personal rights risk to persons in care. POC Due Date: 09/17/2024 Plan of Correction 1 2 3 4 Emergency disaster drills will be conducted at least quarterly and documented. REcord of emergency drill be to sent to CCLD BY DUE DATE.
Regulation
(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions: (3) A written order from a physicia…
Inspector finding
Based on client records review, the licensee did not comply with the section cited above in 6 out of 6 client files reviewed, which poses a potential health, safety or personal rights risk to persons in care. All clients have half bed rails on bed, but there are no MD orders on file. POC Due Date: 09/17/2024 Plan of Correction 1 2 3 4 MD orders for half bed rails for all clients will be sent to CCLD BY DUE DATE
Regulation
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (3) In addition to the on-the-job training requirements in Section 87411(d), staff who provide direct care to residents with dementia shall receive the following training as appropriate for the job assigned and as evidenced by safe and effe…
Inspector finding
Based on review of staff training records, the licensee did not comply with the section cited above, as there is no evidence that staff have received required dementia training. This poses a potential health, safety or personal rights risk to persons in care. POC Due Date: 09/17/2024 Plan of Correction 1 2 3 4 Staff will receive required dementia training. Proof of training to be sent to CCLB BY DUE DATE.
Regulation
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care …
Inspector finding
Based on review of client records, the licensee did not comply with the section cited above in 4out of 6 client files reviewed, which poses a potential health, safety or personal rights risk to persons in care. Clients #1, #3, #4, #6 are diagnosed with dementia, but MD reports and appraisals are dated more than 12 months ago. POC Due Date: 09/17/2024 Plan of Correction 1 2 3 4 MD reports and/or appraisals for clients #1, #3, #4, #6 will be completed and copies to be sent to CCLD BY DUE DATE.
Regulation
Residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (1) To have a reasonable level of personal privacy in accommodations,
Inspector finding
Based on observation, the licensee did not comply with the section cited above, as there is a chair used to weigh all clients stored in room #4 for lack of a common storage area for the chair. This poses a potential health, safety or personal rights risk to persons in care. POC Due Date: 09/17/2024 Plan of Correction 1 2 3 4 Scale chair will be removed from client's room and stored in facility storage area, not in client rooml Proof of correction to be sent to CCLD BY DUE DATE. This deficienc…
Regulation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
Inspector finding
Based on observation, the licensee did not comply with the section cited above, as there are discarded walkers, mattresses, furniture and 13 oxygen tanks in backyard, which poses a potential health, safety or personal rights risk to persons in care. POC Due Date: 09/17/2024 Plan of Correction 1 2 3 4 Backyard will be cleared of discarded furnishings and proof of correction to be sent to CCLD BY DUE DATE.
ComplaintDecember 21, 2023No deficiencies
Inspector: Audrey Jeung
InspectionNovember 21, 2023No deficiencies
Inspector: Audrey Jeung
Plain-language summary
An inspector reviewed client records as part of an annual inspection that began on July 17, 2023. No problems were found with how the facility maintains client records.
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LPA Jeung reviewed client records to continue annual inspection of 7/17/23. No deficiencies related to client records are cited today.
Other visitJuly 17, 2023Type A5 deficiencies
Inspector: Audrey Jeung
Plain-language summary
An inspector toured this six-bedroom facility and found the building itself to be safe, with working smoke and carbon monoxide detectors, adequate lighting and temperature, and proper storage of medications and chemicals. The facility employs awake night staff and has a disaster plan posted. The facility operator was asked to submit several required documents by July 31, 2023, and the inspector will review client records and staff training records at a later date.
View full inspector notes
LPA Audrey Jeung toured facility and grounds. There are no accessible bodies of water or fire safety hazards observed. A comfortable room temperature is maintained, and lighting is sufficient for safety. Carbon monoxide detector is tested and operable. First-aid kit is maintained and complete. This one level facility has 6 client bedrooms, 3 full bathrooms, kitchen/living/dining room. There is a detached staff unit/building that contains a bedroom with one bed, a large room with 2 bunk beds, kitchen, and full bathroom for staff. Awake night staff is employed. Two additional detached storage sheds are in the backyard, and washer and dryer are located in an alcove adjacent to staff unit/building. The backyard is level, paved and landscaped. Some medications are stored in locked hall cabinet and chemicals and cleaners are stored in a detached storage shed. A Disaster and Mass Casualty Plan is posted. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed. Maria Lu Johnson is a certified RCFE administrator (x 7/24) that oversees facility operations. Client records and staff training records will be reviewed at a later date. The following forms are provided and shall be completed and returned to CCL by 7/31/23: • LIC 308 Designation of Administrative Responsibility (signed by licensee designating administrator) • LIC 500 Personnel Report • LIC 610 Emergency Disaster Plan (page 9, signed and dated) • Infection Control Plan (signed and dated) • Proof of liability insurance for $1 million per incident and $3 million in annual aggregate • Staff medication training policy (per H & S 1569.69) Deficiencies of the CA Code of Regulations, Title 22 are cited on following pages.
Regulation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degre…
Inspector finding
Based on observation, the licensee did not comply with the section cited above, as hot water temperature tested at 125 degrees F in middle common bathroom, which poses an immediate health, safety or personal rights risk to persons in care. POC Due Date: 07/18/2023 Plan of Correction 1 2 3 4 Hot water temperature shall be lowered and maintained between 105 and 120 degrees F. Proof of correction to be sent to CCLD BY DUE DATE
Regulation
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.
Inspector finding
Based on observation with administrator,two cans of paint and lighter fluid are stored in unlocked rear storage shed with sliding door and general cleaning supplies and chemicals are stored in another unlocked storage shed with double doors. The licensee did not comply with the section cited above, as toxins were stored where items are accessible to clients, which poses an immediate health, safety or personal rights risk to persons in care. POC Due Date: 07/17/2023 Plan of Correction 1 2 3 4 …
Regulation
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:
Inspector finding
All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility, obtain a California clearance or a criminal record exemption as required by the Department. Based on presence of staff J.G.who does not have criminal record clearance, the licensee did not comply with the section cited above, which poses an immediate health, safety or personal rights risk to persons in care. Staff J.G…
Regulation
INCIDENTAL MEDICAL CARE Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.
Inspector finding
Based on observation, clients' medications that are refrigerated are stored in unlocked small refrigerator in hallway, and excess medications are stored in unlocked drawer in hallway. Licensee failed to ensure that medications are inaccessible to clients, which poses an immediate health, safety or personal rights risk to persons in care. POC Due Date: 07/18/2023 Plan of Correction 1 2 3 4 Clients' medications shall be stored where they are inaccessible to residents. Proof of correction shall…
Regulation
ADDITIONAL PERSONAL RIGHTS Residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (1) To have a reasonable level of personal privacy in accommodations
Inspector finding
Based on observation, there is a chair used to weigh all clients stored in room #4 for lack of a common storage area for the chair. Licensee failed to ensure client's right to personal accommodations by storing facility equipment in client's room. This poses a potential health, safety or personal rights risk to persons in care. POC Due Date: 07/24/2023 Plan of Correction 1 2 3 4 Scale chair will be removed from client's room and stored in facility storage area, not in clients' rooms. Proof …
ComplaintFebruary 3, 2022No deficiencies
Inspector: Audrey Jeung
Plain-language summary
A complaint investigation found that the facility had converted a former office into a bedroom, added a one-bedroom staff apartment in a renovated garage, placed bunk beds in the main living area, and had two unsecured storage sheds in the yard. No violations were cited, though the state requested the facility submit updated room designation sketches and personnel paperwork. The investigator provided additional recommendations in a separate advisory note.
View full inspector notes
During complaint investigation visit, LPA Jeung observed that former office has been designated as a private client room. In addition, the garage has been renovated and now accommodates staff in a 1 bedroom apartment, with a bathroom and kitchen. LPA observed 2 bunk beds in the main living area. In the backyard, there are 2 detached storage sheds, both of which are unsecured. Yard sketch was submitted to CCLD in 2020 showing this. Upon reviewing a client's file, some observations are made. See Advisiory Note for recommendations. The following forms/information are requested to be submitted to CCLD by 2/10/22: - Facility Sketch -- showing designation of rooms - Personnel Report (LIC500) - Designation of Administrative Responsibility (LIC308 signed by licensee designating administrator) No deficiencies cited.
Federal summary
CMS Care CompareNot a CMS-certified facility
California RCFEs (residential care facilities for the elderly) are licensed by the state, not by CMS. CMS data only applies to skilled nursing facilities or to CCRCs that operate a licensed SNF wing.
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