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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600747
Report Date: 06/09/2022
Date Signed: 06/09/2022 11:50:46 AM

Document Has Been Signed on 06/09/2022 11:50 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
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:NANI'S HOMEFACILITY NUMBER:
415600747
ADMINISTRATOR:GOVIND, ANJESHNIFACILITY TYPE:
740
ADDRESS:633 VANESSA DRIVETELEPHONE:
(650) 477-2213
CITY:SAN MATEOSTATE: CAZIP CODE:
94402
CAPACITY: 3CENSUS: 2DATE:
06/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:05 AM
MET WITH:Licensee, Ajenshi GovindTIME COMPLETED:
11:55 AM
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On June 9, 2022, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced annual infection control inspection. Upon arrival LPA observed the COVID signage postage on the front door. LPA met with Licensee, Ajenshi Govind and Administrator, Godfred Gardue joined shortly thereafter. LPA explained the purpose of the visit. LPA was screened at entry point and Licensee was able to provide LPA with screening log documentation for visitors.

LPA toured facility and grounds. No accessible bodies of water or fire safety hazards observed. This is a single story facility with 4 bedrooms; 3 private resident bedrooms, 1 office room and 2 full bathrooms. 1 out of the 3 resident rooms are vacant at this time. Infection control practices are present: entry procedures, face coverings, daily monitoring for residents and staff, COVID-19 signage posted throughout the facility, and 30-day PPE supply. Both bathrooms are equipped with liquid soap, paper towels and trash cans are covered with lids.

LPA toured the kitchen and observed 2 day perishable and 7 day non-perishable present. Medications, toxins and sharps are stored appropriately and inaccessible to residents, and a comfortable temperature is maintained, lighting is sufficient for comfort. First aid kit was observed to be completed. Extra linen was observed to be present.

LPA requested for the following to be submitted to CCLD by 6/16/2022
  • LIC309 Administrative Organization
  • LIC308 Designation of Administrative Responsibility
  • LIC500 Personnel Report
  • LIC400 Resident Cash Resources
  • LIC402 Surety Bond
  • Administrator Certificate
  • LIC610D Emergency Disaster Plan

Report is reviewed with Licensee and Administrator and a copy is provided.
SUPERVISORS NAME: Julio Montes
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE: DATE: 06/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/09/2022
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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