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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 419210066
Report Date: 01/11/2024
Date Signed: 01/11/2024 05:39:49 PM

Document Has Been Signed on 01/11/2024 05:39 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:NONI'S HOMEFACILITY NUMBER:
419210066
ADMINISTRATOR:JOHN RUZZEL B SKAGGSFACILITY TYPE:
735
ADDRESS:717 FALLON AVENUETELEPHONE:
(650) 458-6232
CITY:SAN MATEOSTATE: CAZIP CODE:
94401
CAPACITY: 6CENSUS: 6DATE:
01/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Honodora Balon and Nonito BarisTIME COMPLETED:
05:45 PM
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LPA Audrey Jeung toured facility and grounds, including 3 detached storage sheds, 2 storage cabinets and an accessory dwelling unit in backyard. There are no accessible bodies of water nor fire safety hazards observed. Medications and toxins are stored appropriately and inaccessible to clients, and lighting is sufficient for comfort and safety. Hot water temperature is tested in rear bathroom at 109 degrees. Per legislation--effective 1/1/2015--CCLD Hotline information is posted and there is at least one operable carbon monoxide detector. Food supply and first-aid kit are inspected and complete. Client files are reviewed, including medications. The last disaster drill is documented in August 2023. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed, as well as staff first-aid training records. John Ruzzell Skaggs is a certified ARF administrator (x 5/25) that oversees facility operations. Staff room accommodates 4 live-in staff.

The following updated licensing forms are requested to be submitted to CCLD BY 1/2524:

• LIC 500 Personnel Report
• LIC 308 Designation of Facility Responsibility
LIC 309 Administrative Organization
LIC 999 Facility Sketch (grounds, showing ADU and storage sheds)
Proof of control of property (grant deed of ownership)
• Approved building permit for ADU


Deficiency of the California Code of Regulations, Title 22, is cited on a following page.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Audrey Jeung
LICENSING EVALUATOR SIGNATURE: DATE: 01/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/11/2024
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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Document Has Been Signed on 01/11/2024 05:39 PM - It Cannot Be Edited


Created By: Audrey Jeung On 01/11/2024 at 04:49 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: NONI'S HOME

FACILITY NUMBER: 419210066

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 01/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80010(a)
Limitations on Capacity and Ambulatory Status
(a) A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including the capacity limitation.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on review of client records, the licensee did not comply with the section cited above in 1 out of 6 clients, as client #5 is deemed to be non-ambulatory, which poses a potential health, safety or personal rights risk to persons in care.
According to MD report of 10/2023, client #5 is non-ambulatory, and facility is licensed for ambulatory residents only. However, LPA observed resident communicating with staff and walking.
POC Due Date: 01/25/2024
Plan of Correction
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Plan/proof of correction to be sent to CCLD BY DUE DATE
Type B
Section Cited
CCR
85064(b)
Administrator Qualifications and Duties
(b) All adult residential facilities shall have a qualified and currently certified administrator.

This requirement is not met as evidenced by:
Deficient Practice Statement
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No deficiency cited
POC Due Date: 01/11/2024
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Cara Smith
LICENSING EVALUATOR NAME:Audrey Jeung
LICENSING EVALUATOR SIGNATURE:
DATE: 01/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/11/2024


LIC809 (FAS) - (06/04)
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