<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 389210046
Report Date: 10/31/2024
Date Signed: 10/31/2024 12:30:13 PM

Document Has Been Signed on 10/31/2024 12:30 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 IFACILITY NUMBER:
389210046
ADMINISTRATOR/
DIRECTOR:		MARIA JOSEPHINE NANIOLAFACILITY TYPE:
735
ADDRESS:41 PRETOR WAYTELEPHONE:
(415) 584-4375
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94112
CAPACITY: 6CENSUS: 4DATE:
10/31/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Amabel GabutinaTIME VISIT/
INSPECTION COMPLETED:
12:45 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 10/31/2024, Licensing Program Analyst (LPA) Murial Han and LPA Yi Sam Jian conducted an unannounced annual inspection. LPA met with staff member, Amabel Gabutina, Franzie Gabutina, Pedro Gabutina and Administrator, Maria Naniola, joined shortly there-after. LPA explained the purpose of the visit.

The ground floor had staff bedroom, staff room, staff living room, staff bathroom, staff kitchen, laundry room, and garage. Part of garage had a bed and used as bedroom for staff which is inconsistent with the facility sketch. The second floor had living room, kitchen, 2 bathrooms, and 3 bedrooms for residents. Backyard was fenced, secured, and in good condition. 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 next to the kitchen.

Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed. 1 out of 3 staff's TB result and health screen were not available to review. 4 out of 4 residents' needs and service plans were incomplete due to missing signatures. P&I were reviewed to be accurate for 2 residents.

Deficiencies of the Residential Care Elderly California Code of Regulations, Title 22, Division 6 is observed and cited on a LIC 809D. Failure to correct the deficiencies may result in civil penalties.

This report is reviewed and discussed with the Administrator; a copy and appeal rights are provided.
SUPERVISORS NAME: Andrea Medlin
LICENSING EVALUATOR NAME: Yi Sam Jian
LICENSING EVALUATOR SIGNATURE: DATE: 10/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/31/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
Document Has Been Signed on 10/31/2024 12:30 PM - It Cannot Be Edited


Created By: Yi Sam Jian On 10/31/2024 at 11:36 AM
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: NANIOLA RESIDENTIAL CARE HOME I
FACILITY NUMBER: 389210046

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/31/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80086(a)

80086 Alterations to Existing Building or New Facilities

a) Prior to construction or alterations, all licensees shall notify the licensing agency of the proposed change.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as LPA Jian and LPA Han observed a space in the garage consisted of personal items such as watch, ipad, lotions, computer, desk, bed, chair, etc. and this space is not part of the facility sketch which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/07/2024
Plan of Correction
1
2
3
4
The administrator/licensee will develop a plan in writing indicating either the facility will revert the space back into part of the garage by removing the personal items, furniture, electronics, bed, etc. or proceed with the process of working with CCL and Fire Marshal for approval for the alteration of facility. If the plan is to revert it back to the garage, the administrator will provide photos to proof that the items were removed. If the plan is to work with CCL and Fire Marshal, the plan shall indicate the steps that the facility will take to do so. The administrator/Licensee will provide a copy of the plan to CCL by 11/7/2024.
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
LICENSING EVALUATOR NAME:Yi Sam Jian
LICENSING EVALUATOR SIGNATURE:
DATE: 10/31/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/31/2024


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 10/31/2024 12:30 PM - It Cannot Be Edited


Created By: Yi Sam Jian On 10/31/2024 at 12:02 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: NANIOLA RESIDENTIAL CARE HOME I
FACILITY NUMBER: 389210046

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/31/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(a)(10)
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: (10) A health screening as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 1 out of 3 staffs which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/07/2024
Plan of Correction
1
2
3
4
Licensee will provide documentation of health screening for S3 by POC Due Date.
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
Based on record review, the licensee did not comply with the section cited above in 1 out of 3 staff which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/07/2024
Plan of Correction
1
2
3
4
Licensee will provide documentation of Tuberculosis test result for S3 by POC Due Date.
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
LICENSING EVALUATOR NAME:Yi Sam Jian
LICENSING EVALUATOR SIGNATURE:
DATE: 10/31/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/31/2024


LIC809 (FAS) - (06/04)
Page: 3 of 4