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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600071
Report Date: 04/15/2026
Date Signed: 04/15/2026 02:04:51 PM

Document Has Been Signed on 04/15/2026 02:04 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:HENNELLY HOUSEFACILITY NUMBER:
415600071
ADMINISTRATOR/
DIRECTOR:		STEFANAC, SUZIFACILITY TYPE:
740
ADDRESS:306 - 31ST AVENUETELEPHONE:
(650) 312-8721
CITY:SAN MATEOSTATE: CAZIP CODE:
94403
CAPACITY: 6CENSUS: 5DATE:
04/15/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Caregiver - Talica MatainisigaTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
NARRATIVE
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On 04/14/2026, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced required 1 year annual inspection visit. LPA met with staff Talica Matainisiga and explained the purpose of today's visit. During today's visit there are 5 residents in care and 3 staff present.

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 2 residents on hospice during today's visit. This is a single level facility. The physical plant is toured inside and outside to ensure the safety of the residents. During today's visit LPA observed 4 of the 5 residents. Two are sleeping in bed, one is awake watching TV in their room, and another is receiving home health care. 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. Although both have locks, both locks are not operable at this time. 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. LPA observed fire alarm bells throughout the hallway where residents reside, fire extinguishers through out the facility are observed with inspection dates of 05/20/2025, smoke detector/carbon monoxide detectors are in place through out resident rooms and main hallway, and central heating in the facility as in place.

Continued on next page.
NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: Jaime Vado
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/15/2026
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 5
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: HENNELLY HOUSE
FACILITY NUMBER: 415600071
VISIT DATE: 04/15/2026
NARRATIVE
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Page 2 - LIC809

PPE is in place according to staff. Laundry room is also observed and is full operational and being used on this day. Chemicals and cleaning supplies are stored beneath kitchen sink and in the garage areas. Both areas are lockable. Emergency exit routes are observed inside and outside to be free and clear of obstructions. Resident rooms are observed and all contained the required furniture as outlined in regulations. Water temperature is tested at 110F in common bathroom in main hallway and in 2 resident rooms. LPA asked about emergency drills being conducted, and was informed a recent drill has not been conducted, and there is no record to show. But in speaking with staff, they are knowledgeable of where to go and how to egress in case of an emergency. This poses a potential health and safety risk to staff and residents.

5 of 5 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 are reviewed and showed that R4 and R5 do not have documentation of annual doctor visit. Residents R1, R4 and R5 have a diagnosis of dementia and do not have current physicians report or medical assessments done within one year. This poses an immediate health and safety risk to resident's in care. 3 of staff files reviewed showed that all 3 do not have current first aid cards in place and 1 of 3 have current training. This poses a potential health and safety risk to residents in care.

The following updated forms are being requested to be received by 04/22/2026:

• 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 staff and a copy is provided on this day.
NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: Jaime Vado
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2026
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 04/15/2026 02:04 PM - It Cannot Be Edited


Created By: Jaime Vado On 04/15/2026 at 12:33 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: HENNELLY HOUSE
FACILITY NUMBER: 415600071

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/15/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/16/2026
Section Cited
CCR
87463(h)

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87463(h) Reappraisals - The licensee shall request that all residents receive an annual routine visit with a licensed medical professional once every twelve months, either in person or by video appointment. This regulation has not been met as evidenced by:
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Facility shall create a plan of correction in writing indicating that all resident's shall receive an annual routine medical visit, espeically those diagnosed with dementia.
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Based on file reviews, 3 of 5 residents have not had a recorded annual visit. R1, R4, and R5 have physician's reports that are older than one year with a diagnosis of dementia. This poses an immediate health and safety risk to the residents in care.
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Plan to be recieved by date specified.
Type B
04/17/2026
Section Cited
HSC1569.695(c)

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§1569.695(c)Emergency Plans - A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This regulation has not been met as evidenced by:
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Facility shall create a plan of correction in writing addressing the health and safety code regulation in condcuted drills quarterly. As part of correction, a drill record shall be produced and maintained at the facility to show as evidence of drills being conducted quarterly.
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Based on file reviews and speaking to staff, the facility does not have a diaster drill log and has not conducted a drill within the last 3 months. This poses a potential health and safety risk to residents and staff in care.
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Plan to be recieved by date specified.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
April Cowan
NAME OF LICENSING PROGRAM MANAGER:
Jaime Vado
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/15/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/15/2026


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 04/15/2026 02:04 PM - It Cannot Be Edited


Created By: Jaime Vado On 04/15/2026 at 01:09 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: HENNELLY HOUSE
FACILITY NUMBER: 415600071

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/15/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/22/2026
Section Cited
CCR
87411(c)(1)

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87411(c)(1) Personnel Requirements - General - Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This regulation has not been met as evidenced by:
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Facility shall create a plan of correction in writing indicating that all staff shall maintain a first aid card, and or CPR card, on file at all times. Evidence of current first aid cards is to be received.
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Based on staff files reviewed, 3 of 3 staff do not have current first aid or CPR cards. 2 of 3 expired in March of 2026, and 1 of 3 has an expired card as of 2020. This poses a potential health and safety risk to residents in care.
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Type B
04/24/2026
Section Cited
HSC1569.625(b)(2)

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I§1569.625(b)(2)Staff training - in addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. This regulation has not been met as evidenced by:
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Facility shall create a plan of correction in writing indicating that all staff will receive the annual 20 hours of training as outlined in health and safety code. Evidence of enrollment and completion of trainng is to be received.
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Based on file reviews conducted, 1 of 3 staff does not have current annual training of 20 hours. S1 last training is indicated back in 2022. 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.
April Cowan
NAME OF LICENSING PROGRAM MANAGER:
Jaime Vado
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/15/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/15/2026


LIC809 (FAS) - (06/04)
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