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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 419210066
Report Date: 10/10/2024
Date Signed: 10/16/2024 11:05:53 AM

Document Has Been Signed on 10/16/2024 11:05 AM - 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:NONI'S HOMEFACILITY NUMBER:
419210066
ADMINISTRATOR/
DIRECTOR:		ELIZABETH FRANCOFACILITY TYPE:
735
ADDRESS:717 FALLON AVENUETELEPHONE:
(650) 458-6232
CITY:SAN MATEOSTATE: CAZIP CODE:
94401
CAPACITY: 6CENSUS: 6DATE:
10/10/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Rosario Alipio, Honodora Balon, Elizabeth FrancoTIME VISIT/
INSPECTION COMPLETED:
01:30 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, which is occupied by a family of 4--all of whom have criminal record clearances. 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 front bathroom at 106 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 maintained, and Centrally Stored Medications Records and clients' personal and incidental money records are reviewed. The last disaster drill is documented in July 2024. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed, as well as required staff records. Elizabeth Franco is a certified ARF administrator that oversees facility operations. Staff room accommodates 4 live-in staff.

Copy of approved final building permit for ADU is given to LPA today.
Licensing forms are up to date.



Deficiency of the California Code of Regulations, Title 22, is cited on a following page.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Audrey Jeung
LICENSING EVALUATOR SIGNATURE: DATE: 10/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/10/2024
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 10/16/2024 11:05 AM - It Cannot Be Edited


Created By: Audrey Jeung On 10/10/2024 at 01:07 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: 10/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80065(g)(1)
PERSONNEL REQUIREMENTS
All personnel, including the licensee, administrator and volunteers, shall be in good health, and shall be physically, mentally, and occupationally capable of performing assigned tasks.
... good physical health shall be verified by a health screening, including a test for tuberculosis, performed by or under the supervision of a physician not more than one year prior to or seven days after employment or licensure.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on staff record review, the licensee did not comply with the section cited above in 2 out of 5 staff records reviewed, which poses a potential health, safety or personal rights risk to persons in care.
Staff #1 and #3 have health screenings/TB test results dated more than 12 months prior to their dates of hire. Staff #1 started 11/17/23, and health screening dated 3/2022. Staff #3 started 10/2007 and health screening dated 9/2004.
POC Due Date: 10/24/2024
Plan of Correction
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Health screenings and TB test results for S1 and S3 will be sent to CCLD BY DUE DATE.
Section Cited
Deficient Practice Statement
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POC Due Date:
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:April Cowan
LICENSING EVALUATOR NAME:Audrey Jeung
LICENSING EVALUATOR SIGNATURE:
DATE: 10/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/10/2024


LIC809 (FAS) - (06/04)
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