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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600929
Report Date: 05/31/2024
Date Signed: 05/31/2024 06:29:14 PM


Document Has Been Signed on 05/31/2024 06:29 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:NEVILYN'S HOMEFACILITY NUMBER:
415600929
ADMINISTRATOR:GOMINTONG,NELSON&GRIPO,RFACILITY TYPE:
740
ADDRESS:1702 ECHO AVENUETELEPHONE:
(650) 435-5123
CITY:SAN MATEOSTATE: CAZIP CODE:
94401
CAPACITY:4CENSUS: 4DATE:
05/31/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Maria Godinez- Lopez and Ruth GripoTIME COMPLETED:
06:30 PM
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LPA Audrey Jeung toured facility and grounds. No accessible bodies of water or fire safety hazards are observed. There are 4 private bedrooms for residents and 2 common bathrooms. PPE supply is adequate.. Medications, toxins and sharps are stored appropriately and inaccessible to clients, a comfortable temperature is maintained, and lighting is sufficient for comfort and safety. Soap and paper towels are present in bathrooms and kitchen sink. Toilet and bathing facilities are equipped with grab bars and nonskid flooring material. First-aid kit is inspected and complete. A Disaster and Mass Casualty Plan is posted. There are 4 residents present, and 3 staff. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed. Ruth Gripo and Nelson Gomingtong (x2/25) are certified RCFE administrators that oversee facility operations.

The following forms/information are requested to be updated and submitted to LPA by 6/14/24:

• LIC 309 Administrative Organization
• LIC 400 Affidavit Regarding Client Cash Resources

Personnel Report, page 9 of Emergency Disaster Plan, Designation of Administrative Responsibility, Infection Control Plan and proof of current surety bond are provided to LPA today.

No deficiencies of the RCFE Regulations, California Code of Regulations, Title 22, Division 6, are cited. See Technical Violations issued--3 pages.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:
DATE: 05/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/31/2024
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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