486803527-4-28-2023-21-AS-ACAA-CRBUS4-20230428154944

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486803527
Report Date: 04/28/2023
Date Signed: 04/28/2023 03:50:20 PM

Document Has Been Signed on 04/28/2023 03:50 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME:	NENA & RAY'S GUEST HOME INC. #2		FACILITY NUMBER:	486803527
ADMINISTRATOR:	MAGDALENA CASUGA		FACILITY TYPE:	740
ADDRESS:	985A OAKWOOD AVENUE		TELEPHONE:	(707) 648-2138
CITY:	VALLEJO	STATE: CA	ZIP CODE:	94591
CAPACITY:	5	CENSUS: 4	DATE:	04/28/2023
TYPE OF VISIT:	Case Management - Annual Continuation	UNANNOUNCED	TIME BEGAN:	11:37 AM
MET WITH:	Magdalena "Nena" Casuga		TIME COMPLETED:	02:08 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) Araceli Canela arrived unannounced to continue the Required - 1 Year inspection and met with, Administrator, Magdalena Casuga and Aileen Bryant. This facility is licensed for a total of 5 in which 3 of the residents may be non ambulatory. Facility does not have approval for bedridden, or Hospice. There are currently 3 residents living in the home, not 4 as stated by LPA in the previous report. LPA toured facility and grounds and observed facility was found to be clean at a comfortable temperature, with all exits free from obstruction. 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. Smoke alarms and Carbon monoxide detector are operational. Facility has ceiling fire sprinklers that are serviced and the last inspection was conducted on 3/7/2023. Facility last fire drill was conducted on 3/15/23. LPA previously reviewed all resident files, and some staff files. Staff S1 was fingerprint cleared but facility accidentally noted the wrong facility number and S1 was associated to a sister facility, Nena & Rays Guest Home #3. Facility sent in the required forms to Community Care Licensing to associate S1. Facility will send in copy of staff S1s who was recently hired health screening. Staff training was documented but lacked information from a qualified vendor, certificates or proof of training material. Continue report see LIC809C

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli Canela	TELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:	DATE: 04/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2023

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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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: NENA & RAY'S GUEST HOME INC. #2	FACILITY NUMBER: 486803527
	VISIT DATE: 04/28/2023

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Medication is centrally stored and locked in the office. Facility uses the centrally store log and the Medication Administration Record (MARs). Residents medication is separated in small closed boxes per resident and include an additional list of medication list attached to the top of the container as extra precaution.
LPA toured the wrap around outdoor yard that is fenced. Facility stated some residents come out to smoke in the evening and like to at times be outside in the yard during the day. LPA went over staff being present in the yard at all times residents are out there, to provide supervision and for the residents safety. Facility has sensor motion Lights throughout the yard and in the facility hallways and/or night lights.

LPA discussed the Emergency Disaster Plan and Infection Control Plan.

Licensee/Administrator to submit the current following documents by 5/21/2023:

· LIC 308 Designation of Facility Responsibility
· LIC 500 Personnel Report
· LIC 400 Affidavit Regarding Client/Resident Cash Resources
· LIC 610E Emergency Disaster Plan
· LIC 9020 Register of Facility Residents
Infection Control Plan of Operation (If changes)
Liability Insurance
Copy of current Lease Agreement
Current facility sketch

No citations issued during todays inspection.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli Canela	TELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:	DATE: 04/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2023

LIC809 (FAS) - (06/04)

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