<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600071
Report Date: 07/15/2021
Date Signed: 07/21/2021 03:24:32 PM

Document Has Been Signed on 07/21/2021 03:24 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
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:HENNELLY HOUSEFACILITY NUMBER:
415600071
ADMINISTRATOR:STEFANAC, SUZIFACILITY TYPE:
740
ADDRESS:306 - 31ST AVENUETELEPHONE:
(650) 312-8721
CITY:SAN MATEOSTATE: CAZIP CODE:
94403
CAPACITY: 6CENSUS: 6DATE:
07/15/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Administrator. Kesa VodonaivaluTIME COMPLETED:
02:20 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 7/15/2021, Licensing Program Analyst(LPA) Murial Han conducted an unannounced annual inspection. LPA observed COVID-19 signs posted by the entrance. LPA was greeted by the Administrator, Kesa Vodonaivala. LPA explained the purpose of the visit and LPA was properly screened at the front entrance. .

LPA toured facility and grounds. No accessible bodies of water or fire safety hazards observed. Infection control practices are reviewed: entry procedures, staff training and policies, resident and staff monitoring daily and LPA recommended to complete the symptom review questionnaire and document it accordingly, containment strategies, PPE supply is adequate with environmental preparation and cleaning. Medications, toxins and sharps are stored appropriately and inaccessible to clients, a comfortable temperature is maintained, lighting is sufficient for comfort and safety and food supply was checked and observed to be sufficient. Hand washing stations were equipped with paper supplies and soaps and hand wash signs are posted. First-aid kit is inspected and complete. There are 6 residents present, 3 staff and the Administrator. All the rooms are private with half bathroom.

No deficiency cited today. This report is reviewed and discussed with the Administrator, Kesa Vodonaivalu and a copy is provided.
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE: DATE: 07/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/15/2021
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 1