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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347001016
Report Date: 01/22/2025
Date Signed: 01/22/2025 12:27:35 PM

Document Has Been Signed on 01/22/2025 12:27 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:NELLE HOME PLACEFACILITY NUMBER:
347001016
ADMINISTRATOR/
DIRECTOR:		GIMON, IOANFACILITY TYPE:
740
ADDRESS:5340 NELLE PLTELEPHONE:
(916) 863-1201
CITY:FAIR OAKSSTATE: CAZIP CODE:
95628
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 1DATE:
01/22/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:25 AM
MET WITH:Auruta Gimon, Facility ManagerTIME VISIT/
INSPECTION COMPLETED:
12:40 PM
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Licensing Program Analyst (LPA) Michael Hood arrived at the facility unannounced on 1/22/25 to conduct a Required-1 Year Inspection utilizing the inspection tool.

LPA conducted an inspection of the care home to ensure compliance with Title 22 regulations. There are four (4) bedrooms and three (3) bathrooms for resident use. LPA observed bedrooms to be properly furnished, with appropriate bedding and lighting. The bathrooms were in sanitary condition and properly maintained. Hot water temperature was observed to be 120 degrees F.

LPA checked the kitchen area for the ability to prepare and store food. Care home has required two (2) day perishable and seven (7) day non-perishable food supply on cite. LPA observed knives, cleaning products, and other toxins to be locked away and inaccessible to residents. LPA observed the backyard and perimeter of the care home to be free of clutter and debris. LPA observed smoke detectors and carbon monoxide detectors to be operational in the care home. First aid kit is maintained and ready for emergency use.

LPA reviewed one (1) resident's medications and observed medication to be locked away and inaccessible to the resident. LPA reviewed one (1) resident file and one (1) staff file. Facility has a current copy of certificate of liability insurance and LPA obtained a copy.

As a result of today's inspection, deficiencies are being cited pursuant to California Code of Regulations, Title 22, Division 6, Chapter 8. Deficiencies are listed on 809-D page.

Exit interview was conducted with caregiver. A copy of this report and appeal rights were provided. Signature on these forms acknowledges receipt of these documents.
Anthony PerezTELEPHONE: (323) 485-4915
Michael HoodTELEPHONE: (916) 531-7341
DATE: 01/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/22/2025
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 01/22/2025 12:27 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: NELLE HOME PLACE
FACILITY NUMBER: 347001016

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/22/2025
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records reviewed, the facility did not ensure to obtain a health screening for one (1) of one (1) staff member, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/13/2025
Plan of Correction
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Facility will ensure that all staff obtain a health screening and documentation for health screening is maintained at the facility at all times. Facility will submit copy of missing health screening to LPA by POC due date.
Section Cited
Personnel Requirements - General
(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records reviewed, the facility did not ensure to obtain first aid training for one (1) of one (1) staff member, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/13/2025
Plan of Correction
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Facility will ensure that all staff obtain first aid training and documentation for training is maintained at the facility at all times. Facility will obtained missing first aid card for staff and submit a copy to LPA by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Anthony PerezTELEPHONE: (323) 485-4915
Michael HoodTELEPHONE: (916) 531-7341

DATE: 01/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/22/2025

LIC809 (FAS) - (06/04)
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