380540429-7-17-2024-14-AS-JCAA-D79UQ9-20240717154646

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 380540429
Report Date: 07/17/2024
Date Signed: 07/17/2024 03:47:53 PM

Document Has Been Signed on 07/17/2024 03:47 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:	NANIOLA RESIDENTIAL CARE HOME IV		FACILITY NUMBER:	380540429
ADMINISTRATOR:	NANIOLA, JESSIE R.		FACILITY TYPE:	735
ADDRESS:	798-A HURON AVENUE		TELEPHONE:	(415) 587-7936
CITY:	SAN FRANCISCO	STATE: CA	ZIP CODE:	94112
CAPACITY:	6	CENSUS: 4	DATE:	07/17/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:16 AM
MET WITH:	Maria Naniola, Administrator/Licensee and Christian Rose, Director of Staff		TIME COMPLETED:	03:45 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 July 17, 2024, Licensing Program Analysts(LPAs) John Calandra and Yi "Sam" Jian arrived at the facility at 10:16 AM, to conduct the required unnanounced 1-year Annual Inspection. LPAs Calandra and Jian were greeted by Christian Rose, Director of Staff/caretaker and explained the purpose of their visit. Maria Naniola, Administrator/Licensee joined the visit later. LPAs Calandra and Jian toured the physical plant. This is a 2-story building but residents only reside on the first floor. No accessible bodies of water or hazards were observed. The facility has 4 bedrooms, 2 bathrooms, a living room, dining room, garage, backyard, and staff bedrooms upstairs. The facility was maintained at a comfortable temperature of 70 degrees Fahrenheit. The facility's water temperature was measured between the required 105-120 degrees Fahrenheit. All bedrooms had the required furniture and sufficient lighting. The facility's smoke and carbon monoxide detectors were observed to be functioning. Two smoke detectors had low batteries and the batteries were replaced by the Licensee in the presence of the LPAs. The facility's fire extinguishers were observed to be fully charged and last checked on November 9, 2023. The first aid kit contained the required items such as sterile dressings, bandages, adhesive tape, scissors, tweezers, thermometers, antiseptic solution and guide. The facility had the required 7 days of non-perishables and 2 days of perishables on hand. During the tour of the physical plant, LPAs Jian and Calandra observed a electrical outlet in Bathroom #1 that had an exposed receptacle. LPAs Calandra and Jian spoke to the Licensee/Administrator, Maria Naniola who stated she would get it fixed right away. LPAs Calandra and Jian also reviewed 4 client records and 2 staff records. All were observed to be complete. One staff file was missing. Soap, detergent, poisons, and sharp objects were observed to be locked and in-accessible to persons in care.

SUPERVISOR'S NAME: Andrea Medlin	TELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: John Calandra	TELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 07/17/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2024

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 07/17/2024 03:47 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: NANIOLA RESIDENTIAL CARE HOME IV	FACILITY NUMBER: 380540429
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80066(a)(11)

Personnel Records

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) Tuberculosis test documents as specified in Section 80065(g). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	CCR 80066(a)(11) Personnel Records: Based on observation, the licensee did not comply with the section cited above in 1 out of 1 staff files, which was missing TB test results, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/31/2024
	Plan of Correction
1 2 3 4	Licensee/Administrator 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.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Andrea Medlin	TELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: John Calandra	TELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 07/17/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2024

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: NANIOLA RESIDENTIAL CARE HOME IV	FACILITY NUMBER: 380540429
	VISIT DATE: 07/17/2024

NARRATIVE

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A Type B violation was provided for not having documented TB results for S1.

Technical Violations were provided for having electrical outlets that were not in good repair and not having TB results for S1 at the facility.

LPAs Calandra and Jian requested the following documents from the facility:

-LIC 308-Designation of facility responsibility
-Updated LIC 500
-LIC 309-Administrative Organization

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.

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.

An exit interview was conducted. This report was reviewed with Maria Naniola, Administrator/Licensee and a copy of the report along with Appeal Rights left at the facility.

SUPERVISOR'S NAME: Andrea Medlin	TELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: John Calandra	TELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 07/17/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2024

LIC809 (FAS) - (06/04)

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