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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 389210048
Report Date: 12/15/2022
Date Signed: 12/15/2022 04:12:27 PM

Document Has Been Signed on 12/15/2022 04:12 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
Lookup Error,
, CA
FACILITY NAME:NANIOLA RESIDENTIAL CARE HOME IIIFACILITY NUMBER:
389210048
ADMINISTRATOR:JOHN NANIOLAFACILITY TYPE:
735
ADDRESS:506 PANORAMA DRIVETELEPHONE:
(415) 285-0519
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94131
CAPACITY: 6CENSUS: 6DATE:
12/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Caregiver, Lourdes NobelaTIME COMPLETED:
03:25 PM
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Licensing Program Analyst (LPA) Victoria Bertozzi arrived unannounced to conduct an Annual Required inspection and was greeted by caregiver, Lourdes Nobela. Licensee, Maria Josephine Naniola was unable to come to facility but was available by phone and gave permission for caregiver to sign report. The inspection is focused on the Infection Control procedures and practices of this facility.

Upon entry LPA was screened by caregiver. LPA discussed visitation with caregiver and notified caregiver that clients are able to receive visitors indoors at this time and facilities no longer need to verify visitor vaccination per CCL guidance. LPA initiated a walk-through of the facility around 3:35 pm and observed the following: Facility has COVID-19 posters throughout that included hand washing signs in bathrooms. Facility was a comfortable temperature and exits were free from obstructions. Hand sanitizer is located throughout common areas of the facility. Per caregiver, commonly touched surfaces are disinfected once per day. Facility normally maintains documentation of staff and client daily temperatures but has not documented screening since November 2022. LPA reminded caregiver to continue screening clients and staff daily and to maintain documentation of results.. Staff had masks on during this visit.

Facility has incorporated staff training on infection control and donning and doffing of Personal Protective Equipment (PPE) into their training schedule. Facility has more than a 30 day supply of PPE including but not limited to masks, gowns, and hand sanitizer. Facility maintains a 30 day supply of medication. Fire extinguishers were last serviced May 2022. Smoke detectors and Carbon Monoxide detector were tested and operational.

Continued on LIC809C
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Bertozzi
LICENSING EVALUATOR SIGNATURE: DATE: 12/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/15/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA
FACILITY NAME: NANIOLA RESIDENTIAL CARE HOME III
FACILITY NUMBER: 389210048
VISIT DATE: 12/15/2022
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Continued from LIC809

Licensee/Administrator to submit updates of the following documents to the San Bruno office by 1/15/2023:
LIC 308 Designation of Facility Responsibility (if applicable)
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan (review and update)
Administrator Certificate

No deficiencies cited during this inspection.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Bertozzi
LICENSING EVALUATOR SIGNATURE:

DATE: 12/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2022
LIC809 (FAS) - (06/04)
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