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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600071
Report Date: 04/19/2024
Date Signed: 04/19/2024 11:42:02 AM


Document Has Been Signed on 04/19/2024 11:42 AM - 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:HENNELLY HOUSEFACILITY NUMBER:
415600071
ADMINISTRATOR:STEFANAC, SUZIFACILITY TYPE:
740
ADDRESS:306 - 31ST AVENUETELEPHONE:
(650) 312-8721
CITY:SAN MATEOSTATE: CAZIP CODE:
94403
CAPACITY:6CENSUS: 4DATE:
04/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Co Administrator - Kesa VodonaivaluTIME COMPLETED:
12:00 PM
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On this day, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced required 1 year annual inspection visit. LPA met with co-administrator/staff Kesa Vodonaivalu and explained the purpose of today's visit. LPA asked about the the listed administrator, Suzi Stefanac, and she indicated she is not present on this day but visits the facility multiple times a week.

LPA was allowed entry to the facility. This is a single level facility and is licensed to serve 6 residents all of whom may be non-ambulatory. Facility has a hospice waiver on file for 4 residents. There are no residents on hospice during today's visit according to Kesa. Annual Fees are current. The physical plant is toured inside and outside to ensure the safety of the residents. During today's visit LPA observed 3 of the 4 residents, one of which was still sleeping in bed, and one is at the main dining table having breakfast. LPA observed the facility kitchen which is located adjacent to the dining room. Knives are stored within the kitchen in a drawer adjacent to the sink. Medication cabinet is observed as lockable adjacent and above the counter to the sink. It is unlocked at time of inspection due to staff distributing medications as observed by LPA. Perishable and non-perishable food items are observed as in place in the refrigerator in the kitchen. Additional refrigerator is observed to contain additional food items in the garage. Resident medications are in place and current. The first aid kit is maintained and is complete with required items.

Continued on LIC809C...
SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8865
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:
DATE: 04/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/19/2024
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 3


Document Has Been Signed on 04/19/2024 11:42 AM - 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: HENNELLY HOUSE
FACILITY NUMBER: 415600071

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/19/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/20/2024
Section Cited
CCR
87705(c)(5)

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87705(c)(5) Care of Persons with Dementia - (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: 5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs. This regulation has not been met as evidenced by:
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Facility shall create a plan of correction in writing indicating that resident's diagnosed with dementia shall receive yearly medical assessments and physician's reports. Plan to be recieved by date specified.
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Based on records reviewed on 2 of 4 resident files, LPA observed that R1 and R2 both are diagnosed with dementia and do not have current medical assessments. R1's physicians report is dated 10/12/2020 and R2's physicians report is dated 06/10/2022. This can pose an immediate health and safety risk to resident's in care.
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Type B
04/26/2024
Section Cited
CCR87406(g)

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87406(g) Administrator Certification Requirements - (g) Certificates issued under this section shall be renewed every two (2) years provided the certificate holder has complied with all renewal requirements. This regulation has not been met as evidenced by:
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The facility shall submit evidence of renewal of administrator certificates for all administrators at the facility to the Department by the specified date.
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Based on record reviews conducted, administrator certificate for S1 has expired as of 07/26/2019. This poses a potential health and safety risk to residents in care.
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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: April CowanTELEPHONE: (650) 266-8865
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:
DATE: 04/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/19/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3


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: HENNELLY HOUSE
FACILITY NUMBER: 415600071
VISIT DATE: 04/19/2024
NARRATIVE
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Page 2 - LIC809

LPA observed fire alarm bells throughout the hallway where residents reside,fire extinguishers through out the facility are observed with inspection dates of 10/04/2023, smoke detector/carbon monoxide detectors are in place through out resident rooms and main hallway, and central heating in the facility as in place. PPE is observed in the garage. Laundry room is also observed and is full operational and being used on this day. Emergency exit routes are observed inside and outside to be free and clear of obstructions. Resident rooms were observed and all contained the required furniture as outlined in regulations. Water temperature is tested at 108F in common bathroom in main hallway.

The facility does not handle resident money. Current administrator certificate for Suzi Stefanac is current expiring on 07/15/2024. 2 of 4 resident files are reviewed and 3 staff files are reviewed. LPA cannot confirm valid administrator certificates at time of this visit as the administrator certificate on file had expired on 07/26/2019. This item can pose a potential health and safety risk to residents in care. Resident files reviewed showed that R1 and R2 have a diagnosis of dementia and do not have current physicians report or medical assessments done within one year. This can pose an immediate health and safety risk to resident's in care.

The following updated forms are being requested to be received by 04/26/2024:

• LIC610D Emergency Disaster Plan
• LIC 308 Designation of Administrative Responsibility
• LIC 500 Personnel Report
• Updated administrator certificate
• LIC9020 Client Roster
• Certificate of Liability Insurance

Per the California Code of Regulations, Title 22, Division 6, Chapter 6, deficiencies are cite on the following LIC809D pages. Report reviewed with Kesa Vodonaivalu.
SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8865
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:

DATE: 04/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3