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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600071
Report Date: 05/27/2022
Date Signed: 05/27/2022 12:29:06 PM


Document Has Been Signed on 05/27/2022 12:29 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
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066



FACILITY NAME:HENNELLY HOUSEFACILITY NUMBER:
415600071
ADMINISTRATOR:STEFANAC, SUZIFACILITY TYPE:
740
ADDRESS:306 - 31ST AVENUETELEPHONE:
(650) 312-8721
CITY:SAN MATEOSTATE: CAZIP CODE:
94403
CAPACITY:6CENSUS: 5DATE:
05/27/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:35 AM
MET WITH:Administrator, Kesa VodonaivaluTIME COMPLETED:
12:35 PM
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On May 27, 2022, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced annual inspection. LPA met with Administrator, Kesa Vodonaivalu and explained the purpose of the visit. Upon arrival LPA observed the COVID-19 signage posted at the front door. LPA Charitra was screened at entrance point and Administrator was able to provide LPA with screening log documentation for residents, staff, and visitors.

LPA toured facility and grounds. No accessible bodies of water or fire safety hazards observed. This is a 6 bedroom home with half-baths in each rooms. There is one vacant room at this time. LPA observed one full bathroom. All bathrooms are equipped with liquid soap, paper towels, and a trash cans. LPA advised administrator to ensure that there are not towels in the bathrooms. Infection control practices are present: entry procedures, COVID signage, face coverings, daily monitoring for residents and staff, and 30-day PPE supply.

LPA toured the living room and dining room and it was clear and free from any tripping hazards. A comfortable temperature was maintained, lighting is sufficient. LPA toured the kitchen and medications, toxins and sharps are stored appropriately and inaccessible to residents. First aid kit was observed to be completed. LPA observed 2 day perishable and 7 day non-perishable present.

The following updated forms are requested to be submitted to CCLD by 6/3/22:
• Administrator Certificate
• LIC 308 Designation of Administrative Responsibility
• LIC 500 Personnel Report
• LIC 610E Emergency Disaster Plan
• LIC 400 Resident Cash Resources

Report is reviewed with administrator and a copy is provided. No citations issued during this visit.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 05/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/27/2022
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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