415600747-6-14-2024-14-AS-JCAA-D68W5C-20240614165856

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 415600747
Report Date: 06/14/2024
Date Signed: 06/14/2024 04:59:02 PM

Document Has Been Signed on 06/14/2024 04:59 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:	NANI'S HOME		FACILITY NUMBER:	415600747
ADMINISTRATOR:	GARDUCE, GODFRED		FACILITY TYPE:	740
ADDRESS:	633 VANESSA DRIVE		TELEPHONE:	(650) 477-2213
CITY:	SAN MATEO	STATE: CA	ZIP CODE:	94402
CAPACITY:	3	CENSUS: 2	DATE:	06/14/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:	Violina Rodriguez, Caretaker, Godfred Garduce, Administrator, Anjesni Andrade, Licensee		TIME COMPLETED:	05:00 PM

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 June 14, 2024, Licensing Program Analyst(LPA) John Calandra arrived at the facility at 10:45 AM to conduct the unnanounced Annual 1-year required inspection. LPA Calandra was greeted by Violina Rodriguez, Caretaker and explained the purpose of the visit. Violina Rodriguez, Caregiver called Godfred Garduce, Administrator and Godfred joined the visit later along with Licensee, Anjesni Andrade. LPA Calandra observed 2 clients watching television in the living room and two care staff present at the facility. LPA Calandra toured the physical plant. This is a 1-story building with 2 bathrooms and 3 bedrooms, living room, kitchen, dining room, staff room, garage, front and back yards. All bedrooms had the required furniture and were sufficiently lit. No accessible bodies of water or hazards were observed. The Fire Extinguisher was last inspected on May 13, 2024 and observed to be fully charged. Smoke Alarms and Carbon Monoxide Detectors were observed to be in working condition. Per a conversation with Licensee, Anjesni Andrade, Smoke Alarms and Carbon Monoxide Detectors are directly connected to the fire department. The facility's first aid kit was observed to have the required sterile first aid dressings, bandages, scissors, tweezers, and thermometers. Hot water temperature in all bathrooms was measured between the required 105-120 degrees Fahrenheit. The facility was maintained at a comfortable temperature of 73 degrees Fahrenheit. The facility had the required 7 days of non-perishables and 2 days of perishables on hand. No food was expired. LPA Calandra reviewed 2 client files. All were observed to be complete. LPA Calandra also reviewed 4 staff records, all were observed to be complete except for S1's file which was missing the LIC 503: Health Screening Report and TB results. LPA Calandra interviewed 3 staff and 2 clients. A review of P&I records and money kept at the facility was conducted. All P&I money kept on the premises matched the records kept at the facility.

SUPERVISOR'S NAME: Andrea Medlin	TELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: John Calandra	TELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 06/14/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2024

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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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: NANI'S HOME	FACILITY NUMBER: 415600747
	VISIT DATE: 06/14/2024

NARRATIVE

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A review of Centrally stored medications indicated that medications for residents were properly labeled with instructions on dosage and times of day and matched the Centrally Stored Medication Records(CSMR) kept at the facility.

A Technical Violation was provided for not having documentation of S1's TB test results and S1's Health Screening Report.

No deficiencies were cited during today's visit.

LPA Calandra requested the following documents be sent to the Regional Office:

-LIC 500: Personnel Summary Report
-Liability Insurance

This report was reviewed with Godfred Garduce, Administrator and Anjeshni Andrade, Licensee and a copy of the report left at the facility.

SUPERVISOR'S NAME: Andrea Medlin	TELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: John Calandra	TELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 06/14/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2024

LIC809 (FAS) - (06/04)

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