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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600991
Report Date: 12/30/2020
Date Signed: 01/05/2021 10:47:35 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:NANAY'S HOMEFACILITY NUMBER:
415600991
ADMINISTRATOR:RUTH GRIPOFACILITY TYPE:
740
ADDRESS:2460 EVERGREEN DRIVETELEPHONE:
(650) 255-9951
CITY:SAN BRUNOSTATE: CAZIP CODE:
94066
CAPACITY:4CENSUS: 4DATE:
12/30/2020
TYPE OF VISIT:Case Management - OtherANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Ruth GripoTIME COMPLETED:
10:40 AM
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On this date, Licensing Program Analyst (LPA) Michael Garcia conducted a Case Management visit to provide Technical Assistance (TA) to the facility regarding COVID-19. Due to the pandemic, the visit was conducted remotely. The tele-visit was conducted with Ruth Gripo, administrator, with the assistance of Emma Erickson, RN, of the California Department of Public Health.

The facility's COVID-19 screening and protocol were discussed. The inside of the facility was toured.

According to Ruth, the facility has one (1) staff tested positive for COVID-19. Some staff took the COVID-19 test yesterday and more today. Residents were tested for COVID-19 on December 24, 2020. Ruth is in contact with the Department of Public Health and with the residents' Primary Care Physicians regarding COVID-19 protocols and recommendations.

The visit resulted with the following recommendations:
- Place additional hand sanitizer outside the main entrance by the side garage door,
- And outside the backyard near the door coming back to the facility.
- Post proper hand washing sign next to the hand washing station at the kitchen.
- Continue to submit daily listing of COVID-19 positives (Line List) to licensing.
- Continue with the 25% surveillance testing of staff every 7 days after two (2) rounds of mass testing with all negative test results per PIN 20-38-ASC (provided).

Administrator shall ensure to submit a signed and dated action plan regarding the above recommendations to LPA via email within 24 hours.

Report was discussed with Ruth at the end of the visit. An electronic copy of the report was emailed to Ruth for signature.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Michael GarciaTELEPHONE: (650) 380-4608
LICENSING EVALUATOR SIGNATURE:

DATE: 12/30/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2020
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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