486803265-12-20-2022-21-AS-FSAI-CMAR52-20221220114225

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486803265
Report Date: 12/20/2022
Date Signed: 12/20/2022 11:43:18 AM

Document Has Been Signed on 12/20/2022 11:43 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME:	NENE'S REST HOME		FACILITY NUMBER:	486803265
ADMINISTRATOR:	EVELYN CHAN		FACILITY TYPE:	740
ADDRESS:	2968 VISTA GRANDE		TELEPHONE:	(707) 425-7522
CITY:	FAIRFIELD	STATE: CA	ZIP CODE:	94534
CAPACITY:	6	CENSUS: 2	DATE:	12/20/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:	Interim Administrator, Mary Jane Miranda		TIME COMPLETED:	12:00 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	Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Nene's Rest Home for the purpose of conducting a Required 1 year inspection. LPA was greeted at the door by Interim Administrator, Mary Jane Miranda, and was granted access into the facility. LPA toured the facility with the Interim Administrator, and observed that the facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Fire Extinguisher was found to be last charged on February 2022 at the time of the inspection. All smoke detectors and carbon monoxide detectors were tested and found to be operational during the inspection. First aid kit was inspected and found to be appropriate during the inspection. Water temperature in resident's bathrooms measured at 105 degrees in one bathroom and 133.2 in the other bathroom (See LIC 9102) which is not an acceptable range of 105-120 degrees. There was sufficient perishable and non-perishable foods located in the kitchen. There are special provisions made for individuals with special dietary needs. Food menu was presently available for viewing during the inspection. Medications were centrally stored and locked. Cleaning products and other toxins are located under the kitchen sink and in the laundry room that was locked and inaccessible to residents in care. There was a supply of cleaners, hygiene products and paper products available for residents. All bathrooms designated for residents in the common areas at the facility were supplied with individual paper towels and hand soap dispensers. Bathrooms in resident’s rooms have a towel and soap. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present. A tour of resident’s bedrooms were conducted, and bedrooms inspected have lighting and appropriate furnishing. LPA advised facility to contact County Public Health and Community Care Licensing immediately if symptoms or COVID-19 + in the facility. Facility has PPE which is stored in the hallway closet closest to the front door. Staff at the facility have not been N95 Fit tested (See LIC 9102). (Report continued on LIC 809C)

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan Sarangi	TELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:	DATE: 12/20/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2022

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: NENE'S REST HOME	FACILITY NUMBER: 486803265
	VISIT DATE: 12/20/2022

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LPA requested the following documents to be sent:

LIC 500- Personnel Report
LIC 308- Designation of Responsibility
LIC 309- Administrative Organization
LIC 400- Affidavit regarding Client Cash Resources
Updated facility sketch
Updated Emergency Disaster Plan (LIC 610D)
Surety Bond
Most up-to-date Liability insurance
Control of Property
Register of residents

No deficiencies were cited during today's Required 1 year inspection. Exit interview was conducted and a copy of this report was emailed to the facility Administrator.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan Sarangi	TELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:	DATE: 12/20/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2022

LIC809 (FAS) - (06/04)

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