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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803265
Report Date: 01/27/2024
Date Signed: 01/27/2024 10:58:29 AM


Document Has Been Signed on 01/27/2024 10:58 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:NENE'S REST HOMEFACILITY NUMBER:
486803265
ADMINISTRATOR:MARY JANE MIRANDAFACILITY TYPE:
740
ADDRESS:2968 VISTA GRANDETELEPHONE:
(707) 425-7522
CITY:FAIRFIELDSTATE: CAZIP CODE:
94534
CAPACITY:6CENSUS: 3DATE:
01/27/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Mary Jane MirandaTIME COMPLETED:
11:15 AM
NARRATIVE
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Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a require 1-year inspection utilizing the full CARE tool. LPA met with Administrator, MaryJane Miranda, and explained the purpose of the visit.

Today's census is three residents in care with one resident on hospice services. Facility is licensed for six residents, hospice waiver of two. LPA observed each resident in their private rooms.

LPA and Administrator conducted a tour of the interior and exterior of the facility. Areas toured included but not limited to: residents bedrooms, bathroom, kitchen, backyard, staff room/laundry room, and the common areas. LPA observed fire extinguisher to be serviced on 02/27/2023. LPA reminded Administrator to serviced the extinguisher annually to ensure it is in working condition. LPA observed facility to have the required poster of Long Term Care Ombudsman and Community Care Licensing posted in a conspicuous space. LPA observed Administrator Certificate to be current with expiration date of 01/28/2025. LPA observed facility to have 2+ days of perishable and 7+ days of nonperishable foods.

LPA conducted a file review of R1, R2, R3, S1 and S2. LPA observed no annual training present for S1 and S2's file.

LPA is requesting a copy of LIC 308 and LIC 500 to be submitted to LPA Yang via email by February 2, 2024. LPA obtained a copy of liability insurance.

During today's visit, LPA completed the care inspection tool and deficiency was observed. Please see LIC809-D.

Exit interview conducted, a copy of the report and appeal rights was provided.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (279) 300-5157
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: (916) 201-1928
LICENSING EVALUATOR SIGNATURE:
DATE: 01/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/27/2024
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 01/27/2024 10:58 AM - 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: 01/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in as 2 out of 2 personnel files were missing annual trainings which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/27/2024
Plan of Correction
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Licensee is to submit a compliance plan of how all staff will complete annual trainings in a timely manner.
Plan of Correction is to be submitted to LPA Yang.
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.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (279) 300-5157
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: (916) 201-1928
LICENSING EVALUATOR SIGNATURE:
DATE: 01/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/27/2024
LIC809 (FAS) - (06/04)
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