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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803527
Report Date: 04/27/2023
Date Signed: 04/28/2023 11:18:17 AM


Document Has Been Signed on 04/28/2023 11:18 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:NENA & RAY'S GUEST HOME INC. #2FACILITY NUMBER:
486803527
ADMINISTRATOR:MAGDALENA CASUGAFACILITY TYPE:
740
ADDRESS:985A OAKWOOD AVENUETELEPHONE:
(707) 648-2138
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY:5CENSUS: 5DATE:
04/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:28 PM
MET WITH:Magdalena "Nena" CasugaTIME COMPLETED:
04:35 PM
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Licensing Program Analyst (LPA) Araceli Canela arrived unannounced to conduct a Required - 1 Year inspection and met with, care staff, Christina Manzon. Administrator, Magdalena Casuga and Aileen Bryant were called and arrived later. This facility is licensed for a total of 5 in which 4 of the residents may be non ambulatory. Facility does not have approval for bedridden, or Hospice. There are currently 4 residents living in the home.

LPA toured facility and grounds and observed facility was found to be clean at a comfortable temperature. Facility has at least two days of perishable and one week of non-perishable foods. Fire Extinguisher was found to be charged, and serviced 2/28/2023.

LPA reviewed all resident files, and some staff files. Staff S1 was fingerprint cleared but facility noted the wrong facility number and S1 was associated to a sister facility. S1 works at both Nena & Rays Guest Home #1 and #2 that are combined in this duplex type home and was not associated to either facility. Staff S2, S3 did not have a medical assessment and proof of negative TB when they were hired, records are missing or conducted longer than a year before getting hired and will require proper assessments. Staff training was documented but lacked information from a qualified vendor, certificates or proof of training material.
LPA went over resident R1 who was observed with bandages on their head and facility explained R1 fell while outside in the yard. R1 is a resident from Nena & Rays Guest Home #3. R1 does not have an Admission Agreement for this facility. R1 is sleeping in bedroom #1 of this facility. LPA requested Home Health Records and an update for R1. Incident occurred on 4/20/2023 and resident was sent to Emergency Department and discharged with a head bandage for a laceration.
LPA will continue inspection at a later date, review medication and issue any citations that are warranted.

No Citations issued during this visit.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:
DATE: 04/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/27/2023
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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