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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600747
Report Date: 03/08/2023
Date Signed: 03/08/2023 01:48:49 PM

Document Has Been Signed on 03/08/2023 01:48 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
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:NANI'S HOMEFACILITY NUMBER:
415600747
ADMINISTRATOR:GOVIND, ANJESHNIFACILITY TYPE:
740
ADDRESS:633 VANESSA DRIVETELEPHONE:
(650) 477-2213
CITY:SAN MATEOSTATE: CAZIP CODE:
94402
CAPACITY: 3CENSUS: 3DATE:
03/08/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Licensee, Ajenshi GovindTIME COMPLETED:
01:57 PM
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On March 8, 2023, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced Health and Safety check at the facility to verify a resident transfer was safe. LPA met with Licensee, Ajenshi Govind and Administrator, Godfred Gardue and explained the purpose of the visit.

During the visit, LPA toured the facility and observed newly admitted resident (R1). R1 was sitting on a wheel chair with the Behavioral Consultant and Licensee. According to the Licensee, the staff showered R1, did body checks on him/her, and gave R1 lunch. LPA observed R1's medication supply with the Administrator and observed at least 3 weeks supply of medication. Administrator and Licensee contacted the pharmacy to order items that were not provided from R1's previous facility.

LPA observed the Licensee and Behavioral Consultant talking to R1 and attempting to do activities with him/her. According to the Licensee, the facility is going to take R1 shopping this afternoon to buy more clothes and shoes as R1 was brought to the facility without shoes. R1 appeared comfortable and receptive when staff were talking to him/her. A plan of care will be done by the end of the week. Facility has the Behavioral Consultant scheduled with R1 today, Dietician scheduled tomorrow, and Psychiatrist scheduled Friday. A video call with the dietician was conducted at 12pm today with all staff as well.

No citations issued. Report is reviewed with Licensee and a copy is provided.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE: DATE: 03/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/08/2023
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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