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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803265
Report Date: 01/17/2025
Date Signed: 01/17/2025 06:17:55 PM

Document Has Been Signed on 01/17/2025 06:17 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:NENE'S REST HOMEFACILITY NUMBER:
486803265
ADMINISTRATOR/
DIRECTOR:
MARY JANE MIRANDAFACILITY TYPE:
740
ADDRESS:2968 VISTA GRANDETELEPHONE:
(707) 425-7522
CITY:FAIRFIELDSTATE: CAZIP CODE:
94534
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 3DATE:
01/17/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:55 PM
MET WITH:Administrator, Mary Jane MirandaTIME VISIT/
INSPECTION COMPLETED:
06:25 PM
NARRATIVE
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Licensing Program Analysts (LPAs), Stevenson and Felias arrived unannounced at Nene's Rest Home for the purpose of conducting a Required 1 year inspection. LPAs were greeted at the door by Administrator, Mary Jane Miranda, and was granted access into the facility.

LPAs toured facility with Administrator and observed that the facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Fire Extinguishers were found to be last charged on February 2024. 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. Facility sinks were measured at 137.1F, 135.5F, and 126.5F which is out of compliance with Title 22 Regulation (deficiency cited, LIC809D, regulation 87303(e)(2)). LPAs discussed with Administrator about placing warning signs at sinks that are above 125F. 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. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present. Resident bedrooms had lighting and appropriate furnishing.

LPAs reviewed staff files, resident files, and resident medication. LPAs reviewed 4 staff files. During review, LPAs observed that Staff Member 1 (S1) had current first aid/CPR certification. Staff Member 2 (S2) only had CPR certification but not first aid. Staff Members 3 and 4 (S3 and S4) did not have current first aid/CPR certification as required (deficiency cited, LIC809D, Health and Safety Code, 1569.618(c)(3)). During review of resident files, LPAs observed that 2 of 3 residents were missing updated Needs and Services Plans/LIC625. Resident files were shown to have updated hospice care assessments. LPAs discussed the importance of having a facility care plan separate from the hospice care plan assessment (technical advisory issued, LIC9102, regulation 87463(i)).
Continued on LIC809C
Kimberley MotaTELEPHONE: (707) 588-5051
Star StevensonTELEPHONE: 707-588-5081
DATE: 01/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/17/2025
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: NENE'S REST HOME
FACILITY NUMBER: 486803265
VISIT DATE: 01/17/2025
NARRATIVE
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Continued from LIC809

During visit, Administrator informed LPAs that during nighttime there is not a designated staff member awake to assist residents. LPAs informed Administrator that they are required to have at least one night staff person awake and on duty based on the size of their facility and the residents they serve (technical advisory issued, LIC9102, regulation 87705(b)(2)). LPAs obtained a copy of facility's most current LIC500 (Personnel Report).

Administrator Certificate for Mary Jane Miranda (701663740) is current with an expiration date of 01/28/2025. Review of Department's Administrator Certification list indicated that Administrator renewal application had been received as of 12/23/2024.

LPAs and Administrator discussed hospice waiver increases and hospice waiver exceptions.

LPAs requested the following documents to be sent:
LIC 500- Personnel Report
LIC 308- Designation of Responsibility
LIC 400- Affidavit regarding Client Cash Resources
LIC9020 Register of Residents
Updated facility sketch
Updated Emergency Disaster Plan (LIC 610E)
Most up-to-date Liability insurance
Control of Property

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Exit interview conducted. Copy of report, LIC809D (Deficiency Page), LIC9102 (Technical Advisories/Violations), Confidential Names (LIC811), Plan of Corrections, and Appeal Rights discussed and provided to Administrator. Signature on form confirms receipt of documents.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Star StevensonTELEPHONE: 707-588-5081
LICENSING EVALUATOR SIGNATURE:

DATE: 01/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/17/2025 06:17 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405


FACILITY NAME: NENE'S REST HOME

FACILITY NUMBER: 486803265

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 01/17/2025
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and interview with administrator, licensee did not comply with the section cited above. 1 of 4 employees had current CPR and 1st aid, 1 of 4 employees had current CPR and 2 of 4 employees had no CPR or 1st Aid. This poses an immediate health, safety or personal rights risk to residents in care.
POC Due Date: 01/18/2025
Plan of Correction
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Llcensee to submit proof of paid enrollment for identified employees needing current 1st Aid and CPR certification. Licensee to submit proof of scheduled enrollment by POC due date of 01/18/2025. LIcensee to sumit proof of certificates once classes are completed.
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.
Kimberley MotaTELEPHONE: (707) 588-5051
Star StevensonTELEPHONE: 707-588-5081

DATE: 01/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/17/2025

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/17/2025 06:17 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405


FACILITY NAME: NENE'S REST HOME

FACILITY NUMBER: 486803265

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 01/17/2025
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
87303 Maintenance and Operation: (e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations, Licensee did not comply with the section cited above. Facility sink temperatures measured at 137.1F, 135.5F, and 126.5F. This poses a potential health, safety or personal rights risk to residents in care.
POC Due Date: 01/28/2025
Plan of Correction
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Licensee to submit a water temperature log for 10 days for all facility sinks. Temperature to be checked twice a day starting 01/18/2025 and ending 01/28/2025. Log to include time when water was checked. Log to be submitted to CCL for review and approval by POC due date 01/28/2025.
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.
Kimberley MotaTELEPHONE: (707) 588-5051
Star StevensonTELEPHONE: 707-588-5081

DATE: 01/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/17/2025

LIC809 (FAS) - (06/04)
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