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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600991
Report Date: 08/30/2023
Date Signed: 08/30/2023 05:38:00 PM


Document Has Been Signed on 08/30/2023 05:38 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: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:
08/30/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Administrator, Ruth GripoTIME COMPLETED:
12:00 PM
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On August 30, 2023 Licensing Program Analyst(LPA) Murial Han conducted an unannounced annual inspection. LPA was greeted by administrator, Ruth Gripo and LPA explained the purpose of the visit.

LPA toured the facility inside and outside including the bedrooms (4 private rooms), 2 full- bathrooms, kitchen, 2 living and dining rooms. The facility observed to be cleaned, tidy and in good repair. Bedrooms were equipped with the required furniture for residents to use. Bathrooms are equipped with grab bars, and nonskid mats. Facility temperature is comfortable. Tap delivering water in the kitchen measured at 105 degrees (F) and hot water temperature in the bathrooms were measured at 105-108 degrees F.

Central stored medication, toxins and sharps objects were observed to be locked and inaccessible to residents.

Emergency drills, central stored medication, and staff training records were reviewed.

Food supplies were observed to be adequate.

Facility is equipped with smoke detectors and carbon monoxide detectors. Fire extinguisher was last serviced on May 17, 2023.

Staff records were reviewed and contained criminal clearance, first aid / CPR certificate, Job Description, Abuse Statement, Health Screening with TB test result and criminal record statement.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:
DATE: 08/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/30/2023
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 2


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: NANAY'S HOME
FACILITY NUMBER: 415600991
VISIT DATE: 08/30/2023
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LPA reviewed resident's files contained resident's identification and emergency information, admission agreement, medical assessment, LIC 602 (Physician Order), Appraisal Needs and Service Plan, GGRC/IPP, etc.

LPA reviewed P & I records for 4 residents, reconciled cash on hand with attached receipts.

During today's inspection, there is 4 residents present.

No deficiency cited today; Technical Violation observed.

This report is reviewed and discussed with the administrator. A copy is provided.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:

DATE: 08/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2023
LIC809 (FAS) - (06/04)
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