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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385600385
Report Date: 09/29/2026
Date Signed: 09/29/2026 03:04:53 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 09/29/2026 03:04 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:CORINTHIAN GARDEN RESIDENTIAL CARE HOMEFACILITY NUMBER:
385600385
ADMINISTRATOR/
DIRECTOR:		ENCARNACION, WILLIAM S.FACILITY TYPE:
740
ADDRESS:170 APTOS AVENUETELEPHONE:
(415) 841-0311
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94127
CAPACITY: 6CENSUS: 4DATE:
09/29/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:34 PM
MET WITH:William EncarnacionTIME VISIT/
INSPECTION COMPLETED:
03:20 PM
NARRATIVE
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On 9/29/2026, Licensing Program Analyst (LPA) Jian conducted an unannounced Annual Required – 1 yr. inspection for this facility and was greeted by Licensee, William Encarnacion. LPA explained the purpose of the visit.
LPA continued with a tour of the facility with staff, resident’s bedrooms, common areas, kitchen & food storage areas were inspected. All outdoor and indoor passageway were free and clear of obstruction. No accessible bodies of water or fire safety hazards observed. Kitchen was inspected, sufficient supply of food observed. Infection control practices reviewed. Medications, toxins and sharps stored appropriately and inaccessible to clients, a comfortable temperature was maintained, hot water temperature inspected to be compliant, furnishing and lighting was sufficient for comfort and safety. Carbon monoxide detector and smoke detector system inspected and met the requirements. fire extinguisher checked and fully charged. Facility has a written emergency disaster plan. Licensee has at least one completed first aid kit located in the kitchen.
Deficiency cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties. See technical violation for documentation of appraisal for residents and CPR first aid training for staff. Exit interview conducted with licensee and appeal rights provided. This report is reviewed and discussed with the licensee and a copy is provided.
Brenda Chan
Yi Sam Jian
DATE: 09/29/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/29/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 09/29/2026 03:04 PM - It Cannot Be Edited


Created By: Yi Sam Jian On 09/29/2026 at 02:13 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: CORINTHIAN GARDEN RESIDENTIAL CARE HOME
FACILITY NUMBER: 385600385

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/29/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/30/2026
Section Cited
CCR
87555(a)

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87555 General Food Service (a) All food shall be selected, stored, prepared and served in a safe and healthful manner. This requirement is not met as evidenced by: LPA observed a piece of raw meat lay in a metal tray exposed to air and set on kitchen counter top next to sink. which poses/posed immediate health, safety or personal rights risk to persons in care.
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The facility will develop a written plan to ensure that All food shall be stored, prepared and served in a safe and healthful manner. The facility will submit a copy of the written plan to CCL by POC due date.
Type B
10/09/2026
Section Cited
HSC
1569.695(a)(2)

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1569.695(a)(2) Plans for the facility to be self-reliant for a period of not less than 72 hours immediately following any emergency or disaster... If the facility plans to shelter in place and one or more utilities, including water, sewer, gas, or electricity, is not available...
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The facility will develop a written plan to ensure that supplies of drinking water will be available for the facility to be self-reliant for period of not less than 72 hours immediately following any emergency or disaster. The facility will submit a copy of the written plan to CCL by POC due date.
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This requirement is not met as evidenced by: LPA observed no drinking water for residents and licensee reported facility ran out of emergency drinking water for the residents, which poses/posed a potential health, safety or personal rights risk to persons in care.
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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.
Brenda Chan
NAME OF LICENSING PROGRAM MANAGER:
Yi Sam Jian
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/29/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/29/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/29/2026 03:04 PM - It Cannot Be Edited


Created By: Yi Sam Jian On 09/29/2026 at 02:22 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: CORINTHIAN GARDEN RESIDENTIAL CARE HOME
FACILITY NUMBER: 385600385

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/29/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/09/2026
Section Cited
CCR
87463(h)

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87463(h) The licensee shall request that all residents receive an annual routine visit with a licensed medical professional once every twelve months, either in person or by video appointment. This requirement is not met as evidenced by:
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The facility will submit a documentations demostrating that 4 resident receive an annual routine visit with a licensed medical professional once every twelve months to CCL by POC due date.
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Facility did not provide documentations for 4 out of 4 resident receive an annual routine visit with a licensed medical professional once every twelve months, which poses/posed a potential health, safety or personal rights risk to persons in care.
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Type B
10/09/2026
Section Cited
CCR87211(a)(1)

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87211(a)(1)A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of ...This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and
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Licensee agrees to complete and submit the written death report to Licensing by POC due date.
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disposition of the case. (A)Death of any resident from any cause ...
Documentation of the death report for resident was not completed or submitted to Licensing within reporting requirements. This serves as a potential personal rights and safety risk to residents.
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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.
Brenda Chan
NAME OF LICENSING PROGRAM MANAGER:
Yi Sam Jian
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/29/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/29/2026


LIC809 (FAS) - (06/04)
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