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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803265
Report Date: 02/12/2025
Date Signed: 02/12/2025 04:37:26 PM

Document Has Been Signed on 02/12/2025 04:37 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:
02/12/2025
TYPE OF VISIT:OfficeUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
04:00 PM
MET WITH:Licensee, James Miranda, and Staff Member, Dave MirandaTIME VISIT/
INSPECTION COMPLETED:
04:45 PM
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An Office Informal meeting was conducted today in the Santa Rosa Regional Office. The following individuals were present in the meeting: Licensing Program Manager, Victoria Bertozzi, Licensing Program Analysts, Caitlynn Felias and Star Stevenson, Licensee, James Miranda, and Staff Member, Dave Miranda. The purpose of today’s meeting was to address staffing concerns identified by the Department. During visits conducted on 01/17/2025 and 01/27/2025, LPAs Felias and Stevenson observed Administrator, Mary Jane Miranda, perform Administrator duties, caregiver duties, and personal child care duties for their two children.

Review of facility documents showed that 2 of 3 residents are receiving hospice care, require nighttime supervision, and require assistance with feeding. 1 of 3 residents is required to be handfed. 1 of 3 residents is bedbound while 2 of 3 residents are non-ambulatory. All 3 residents would need assistance from staff to evacuate in the event of an emergency. 3 of 3 residents require assistance with the following activities of daily living:
· Help with transferring
· Bathing
· Dressing
· Incontinence care/toileting
· Medication management
In addition, interviews conducted with facility staff indicated that the Administrator also takes care of their two children, under the age of 8, during facility hours.

The following areas were discussed during the meeting today:
· Administrator Duties
· Staffing and Care Needs of Residents

Continued on LIC809C
Victoria BertozziTELEPHONE: (707) 588-5059
Caitlynn FeliasTELEPHONE: 707-588-5039
DATE: 02/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/12/2025
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: 02/12/2025
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Continued from LIC809

Parties discussed facility's plan moving forward regarding staffing. Facility has hired an additional staff and has made changes to ensure residents' needs are met. Per discussion, Staff Member, Dave Miranda, will be providing childcare to alleviate the other caregiver of these duties as well as provide care on the NOC shift and throughout the day, as needed. Residents' on hospice are also being provided additional bathing during the week by the hospice agency.

Department requested that an updated LIC500 be submitted to Community Care Licensing by due date of 02/24/2025. LPA will follow up with The Guardian regarding fingerprints of newly hired staff.

No Deficiencies Cited during office meeting.

Exit interview conducted. Copy of report discussed and provided to Licensee. Signature on form confirms receipt of documents.
SUPERVISOR'S NAME: Victoria BertozziTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Caitlynn FeliasTELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:

DATE: 02/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2025
LIC809 (FAS) - (06/04)
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