Britannia Place

Type of visit: Required - 1 Year

On 2/4/2026, Licensing Program Analyst(LPA) John Calandra arrived at the facility to conduct the Annual 1-year required inspection. LPA Calandra was greeted by Mark Williams, Administrator and explained the purpose of the visit. Delphine Williams, Licensee arrived later during the visit. LPA toured the physical plant. This is a 1-story building with 5 bedrooms (4 for residents and 1 for staff), 2 bathrooms, a dining room, kitchen, living room, front and backyards, etc. No accessible bodies of water or hazards were observed in hallways or the front or back yards. The facility's fire alarms and Carbon Monoxide detector were observed to be in working order. The facility's first aid kit was observed to have all required items. The facility had the required 7 days of non perishables and 2 days of perishables on site. No food was expired. The facility was maintained at a comfortable temperature of 70 degrees Fahrenheit. The facility's hot water was measured between the required 105-120 degrees Fahrenheit. All sharp objects, soap, detergents, and poisons were observed to be locked and in-accessible. A review of Centrally Stored Medications indicated that medications for residents were properly labeled with instructions on dosage and times of day and matched the Centrally Stored Medication Records(CSMR) kept at the facility. LPA requested a copy of the facility's updated Plan of Operation by 2/13/2026. While at the facility, LPA collected the facility's transportation policy, Administrator certificate, and Liability Insurance. No deficiencies cited during today's visit. An exit interview was conducted. A copy of this report was provided to the facility representative.the state’s words, verbatim · CDSS document, Feb 4, 2026

Type of visit: Case Management - Other

On 8/19/2025, LPA Calandra arrived at the facility to conduct a Case Management visit quarterly check-in regards to an Non-Compliance conference held on 12/11/2024. LPA Calandra was greeted by Delphine Williams, Licensee and explained the purpose of a visit. The NCC meeting on 12/11/2024 was called to discuss a serious violation that occurred on 09/04/2024 in which a resident was able to elope from the facility. During today's quarterly check-in, LPA observed adequate staffing and that all trainings discussed in the Plan of Correction have been completed. LPA requested a copy of the facility's LIC 500-Personnel report be sent to the Department by 8/22/2025. LPA received copy of the facility roster at the facility. No deficiencies were cited during today's visit. An exit interview was conducted. This report was reviewed with Delphine Williams, Licensee and a copy of the report left at the facility.the state’s words, verbatim · CDSS document, Aug 19, 2025

Type of visit: Case Management - Other

On 4/24/2025, LPA Calandra arrived at the facility to conduct a Case Management visit quarterly check-in regards to an Non-Compliance conference held on 12/11/2024. LPA Calandra was greeted by Mark Williams, Administrator and explained the purpose of a visit. The NCC meeting on 12/11/2024 was called to discuss a serious violation that occurred on 09/04/2024 in which a resident was able to elope from the facility. During today's quarterly check-in, LPA observed adequate staffing and that all trainings discussed in the Plan of Correction have been completed. LPA obtained a copy of the sign-in sheet for the trainings during the visit. No deficiencies were cited during today's visit. An exit interview was conducted. This report was reviewed with Mark Williams, Administrator and a copy of the report left at the facility.the state’s words, verbatim · CDSS document, Apr 24, 2025

Type of visit: Case Management - Other

On February 14, 2025, Licensing Program Analyst(LPA) John Calandra arrived at the facility to deliver an Amended report from 2/7/2025. LPA Calandra was greeted by Delphine Williams, Licensee and explained the purpose of the visit.the state’s words, verbatim · CDSS document, Feb 14, 2025

Type of visit: Required - 1 Year

***************************************THIS IS AN AMENDED REPORT************************************************** On 2/7/2025, Licensing Program Analyst(LPA) John Calandra arrived at the facility to conduct the Annual 1-year required inspection. LPA Calandra was greeted by Dionisio Rigor, Caregiver and explained the purpose of the visit. Delphine Williams, Administrator/Licensee arrived later during the visit. LPA toured the physical plant. This is a 1-story building with 5 bedrooms (4 for residents and 1 for staff), 2 bathrooms, a dining room, kitchen, living room, front and backyards, etc. No accessible bodies of water or hazards were observed in hallways or the front or back yards. The facility's fire alarms and Carbon Monoxide detector were observed to be in working order. The facility's first aid kit was observed to have all required items. The facility had the required 7 days of non perishables and 2 days of perishables on site. No food was expired. The facility was maintained at a comfortable temperature of 70 degrees Fahrenheit. The facility's hot water was measured between the required 105-120 degrees Fahrenheit. All sharp objects, poisons, and detergents were observed to be locked and in-accessible to persons in care. LPA reviewed 3 resident records and 3 staff files. All were observed to be complete. A review of Centrally stored medications indicated that medications for residents were properly labeled with instructions on dosage and times of day and matched the Centrally Stored Medication records kept at the facility. An exit interview was conducted. This report was reviewed with Mark Williams, Administrator and a copy of the report left at the facility.the state’s words, verbatim · CDSS document, Feb 7, 2025

Type of visit: Office

On December 11, 2024, San Bruno Regional Office conducted a non-compliance conference meeting with Licensee/Administrator, Delphine Williams and Mark Williams at 2:45 PM. Present in the meeting was Regional Manager, Vivien Helbling, Licensing Program Manager, April Cowan, and Licensing Program Analyst, John Calandra. The meeting was called to discuss a serious violation that occurred on 09/04/2024 in which a resident was able to elope from the facility. During the non-compliance meeting, the following violations were discussed: -Care of Persons with Dementia - Basic Services -Care of Persons with Dementia 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. An LIC421IM form issuing an immediate civil penalty of $500 was provided to Delphine Williams, Licensee. The immediate civil penalty of $500 was issued today due to absence of supervision that occurred on 09/4/2024 in which a resident eloped from the facility without staff supervision. Deficiencies are cited under California Code of Regulations, Title, 22 cited on the LIC 809D. Failure to correct the deficiencies may result in civil penalties. Report was reviewed with Licensee/Administrator, Delphine Williams and Mark Williams and a copy of this report and the Appeal Rights are provided.the state’s words, verbatim · CDSS document, Dec 11, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(c)(4) · Plan of correction due date: Dec 12, 2024

CCR87705(c)(4) Care of Persons with Dementia: (4) There is an adequate number of direct care staff to support each resident’s physical... This requirement was not met as evidenced by: Based on record review, facility did not have adequate personnel to work at the time of the elopement incident. S1 was taking care of 5 residents at time of incident. This is an immediate health, safety, or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Dec 11, 2024

Plan of correction: Licensee shall develop a plan of operation in writing describing how facility shall ensure that personnel will be adequate in numbers at all times. Licensee stated they will have staff notice the Licensee and Administrator that the staff member is going on break to ensure that the residents are taken care of adequately.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87464(f) · Plan of correction due date: Dec 12, 2024

87464 Basic Services: (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement is not met as evidenced by: Based on interviews, Licensee did not provide care and supervision to a resident diagnosed with Dementia who eloped. Staff were aware resident had eloped from the facility as S1 was providing care to a resident and supervising five residents when R1 eloped from the facility but could not leave persons in care unassisted.the state’s words, verbatim · CDSS document, Dec 11, 2024

Plan of correction: Licensee shall develop a plan in writing detailing additional staff training that will take place to ensure that care and supervision will be provided to every resident in care. Licensee will continue to conduct appraisals and needs and services plans. Licensee will also adhere to the updated LIC 500.

Type of visit: Case Management - Other

On September 27, 2024, Licensing Program Analyst (LPA) John Calandra arrived at the facility to conduct an unannounced Case Management visit to follow up on an incident report sent by the facility to the department on September 5, 2024, in which R1 left the facility unassisted. LPA Calandra was greeted by Dionisio Rigor, Caretaker and explained the purpose of the visit. Delphine Williams, Administrator/Licensee and Mark Williams, Administrator arrived later during the visit. Based upon review of R1’s records, LPA Calandra found that R1 has a primary diagnosis of Alzheimer’s and is not cleared to leave the facility unassisted by the physician. Thus, R1 should not have been able to wander away from the facility. LPA and Administrator discussed several items including staff training plans, and other preventative measures in order to prevent further incidents of wandering from occurring. A Type A violation was provided for not ensuring the facility’s plan of operations addresses safety measures to address behaviors such as wandering and aggressive behaviors. The deficiencies are cited under the California Code of Regulations, Title 22. Failure to correct the deficiencies by the due date may result in civil penalties. An exit interview was conducted. This report was reviewed with Delphine Williams, Administrator/Licensee and Mark Williams, Administrator, and a copy of the report along with Appeal Rights left at the facility.the state’s words, verbatim · CDSS document, Sep 27, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(b)(2) · Plan of correction due date: Sep 28, 2024

(b) In addition to the requirements as specified in Section 87208, Plan of Operation, the plan of operation shall address the needs of residents with dementia, including: (1)Procedures for notifying the resident’s physician, family members and responsible persons who have requested notification, and conservator, if any, when a resident’s behavior or condition changes. (2) Safety measures to address behaviors such as wandering, aggressive behavior and ingestion of toxic materials. This requirement is not met as evidenced by incident report, interviews with staff and review of R1’s records, which showed that the resident was able to wander away from the facility without staff supervision. This is an immediate health/safety risk to persons in care.the state’s words, verbatim · CDSS document, Sep 27, 2024

Plan of correction: Administrator/Licensee to submit proof of correction and a written plan outlining how this violation will be avoided in the future to licensing office by due date.

Type of visit: Case Management - Other

On September 19, 2024, Licensing Program Analyst(LPA) John Calandra arrived at the facility to conduct a Case Management visit in regards to an incident that occurred on September 4, 2024 in which a client was able to leave the facility unassisted. LPA Calandra was greeted by Licensee/Administrator, Delfine Williams and explained the purpose of the visit. Mark Williams, Administrator arrived later during the visit. LPA Calandra requested the following documents: -Current resident files -LIC 602 for resident -Needs and Services Plan for resident -Updated LIC 500 During the visit, LPA Calandra observed 1 resident in the living room watching tv, 2 residents sleeping in their bedrooms, and 1 resident in their bedroom sitting in their chair visiting with their relative. Based on LPA's review of documents including LIC 602-Physician's reports for all current residents and R1, Needs and Services plan for R1, facility's program description, interview with staff, etc., it was determined that the facility did not violate Title 22 or the Health and Safety code. No deficiencies were cited during today's visit. An exit interview was conducted. This report was reviewed with Mark Williams, Administrator and Delfine Williams, Administrator/Licensee and a copy of the report left at the facility.the state’s words, verbatim · CDSS document, Sep 19, 2024

Type of visit: Required - 1 Year

On 02/15/2024 Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced 1 year annual inspection visit. LPA met with administrator Mark Williams and explained the purpose of today's visit. LPA toured the facility inside and outside. Emergency exit routes are free and clear of obstructions. The facility's ambient temperature is comfortable and warm. Water is tested in two bathrooms as being 110F. Residents have an adequate amount of linens and incontinence supplies, incidental supplies, as well as PPE as needed. Linens are stored in a resident bathroom located at the rear of the facility. One fire extinguisher is observed at the end of the hallway centralized to resident rooms and laundry nook. Extinguisher is observed as being inspected 11/27/2023. Carbon monoxide detectors and smoke detectors are present through out the facility. Resident bathrooms are observed to be in working order with clean shower curtains and non-skid surfacing and strips are in place. Some residents bring their own toiletries to the bathrooms and some are stored and provided by staff upon request. 7 day non-perishable food supply and 2 day fresh food supply is observed as in place. Kitchen is observed as operable and clean. Appliances are in good working order. Knives are stored and locked in hallway cabinet along with cleaning solutions. Medications are stored and inaccessible in a locked medication cabinet in the kitchen. Medications are reviewed to be in place and accurately marked in bubble packs and medication bottles. Centrally stored medication log is observed as current. First aid kit is complete and stored in hallway closet. On site laundry is available and functioning per observations made in at the end of the hallway central to two resident rooms Continue on next page... Page 2 - LIC809C 3 staff records are reviewed. All staff has criminal record clearance and are associated with the facility. Based on record reviews, TB tests, training, CPR/First Aid cards, and personnel files are current. 2 client records are checked and both are complete and updated. Disaster drills are current and vary per month. Last conducted in 12/24/2023. According to administrator each drill is different and varies for each drill conducted. Administrator certificate is observed is observed as current expiring 05/19/2024. Facility does not handle resident money. The following updated items are requested to be sent to the Department by 02/22/2024: • LIC610D Emergency Disaster Plan • LIC 308 Designation of Administrative Responsibility • LIC 500 Personnel Report • Updated administrator certificate • LIC9020 Client Roster • Certificate of Liability Insurance • Proof of control of property • Surety bond with expiration date Report is reviewed with administrator. No citations issued.the state’s words, verbatim · CDSS document, Feb 15, 2024