<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600747
Report Date: 07/10/2023
Date Signed: 07/10/2023 11:41:53 AM


Document Has Been Signed on 07/10/2023 11:41 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
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:
07/10/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Administrator, Godfred GarduceTIME COMPLETED:
11:50 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On July 10, 2023, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced annual inspection. LPA met with Licensee, Anjeshni Govind and Administrator, Godfred Garduce and explained the purpose of the visit. Upon arrival, temperature was taken and shoes were disinfected.

LPA toured the facility and grounds. No accessible bodies of water or fire safety hazards observed. This is a single story home with 3 single resident rooms and 2 full bathrooms. LPA toured the resident rooms and observed them to be private rooms with all required furniture. Door alarms were observed to be working. Bathrooms were observed to be clean and odor free. Non-skid mats and grab bars were observed to be present. Extra linen was observed to be present,

Living room and dining room was observed to be clean and free from any tripping hazards. A comfortable temperature is maintained and lighting is sufficient for comfort. Kitchen was observed to be clean. Sharps and medications were observed to be locked and inaccessible to residents. 2 days for perishables and 7 days non-perishable was observed. Toxins and chemicals were observed in the garage in a locked cabinet. Washer and dryer was in good repair.

LPA reviewed 3 staff files and 3 resident files. Resident records are updated, complete and signed. Staff records are observed to be completed with training logs. Emergency drills are conducted and documented every 3 months. Residents were observed to be playing with staff and watching television.

Medication review was done, and all medications are accounted for, and centrally stored medication records are current.

No citations are issued during this visit. Report is reviewed with Administrator and a copy is provided.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 07/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/10/2023
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 1