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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803528
Report Date: 05/27/2021
Date Signed: 06/01/2021 02:47:49 PM

Document Has Been Signed on 06/01/2021 02:47 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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:NENA & RAY'S GUEST HOME INC. #1FACILITY NUMBER:
486803528
ADMINISTRATOR:MAGDALENA CASUGAFACILITY TYPE:
740
ADDRESS:985B OAKWOOD AVENUETELEPHONE:
(707) 648-2138
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY: 6CENSUS: 4DATE:
05/27/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Administrator, Aileen BryantTIME COMPLETED:
04:31 PM
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Licensing Program Analyst (LPA) A. Canela arrived unannounced to conduct an Annual Required inspection and met with Backup Administrator, Aileen Bryant. The inspection is focused on the Infection Control procedures and practices of this facility.

Upon arrival, LPA observed that facility has a table just inside of the entrance to the facility with hand sanitizer, masks and a thermometer. Staff screened LPA and requested LPA to sign in. Per conversation with Administrator, they check the temperature of visitors and asks them screening questions. LPA suggested adding a field to the sign-in sheet where visitors can put in their contact information for record contact tracking purposes. LPA conducted a walk-through of the facility with the administrator and observed Covid-19 posters throughout the facility that includes hand washing and directions to cover coughs. LPA asked if 25% of staff are surveillance testing weekly and administrator stated they weren't because everyone is vaccinated. LPA four clients in the home. Facility staff have completed PPE training but have not yet been N-95 Fit tested. Facility is disinfected throughout the day.

Facility has submitted and received approval for a Covid Mitigation plan. Facility has a 30 day supply of PPE and medication. Most clients do not typically wear masks inside the facility but staff do encourage mask wearing when outside of the facility. Staff had masks on during this visit. Staff have discussed with clients the importance of mask wearing and social distancing while in the community.

LPA provided the following guidance to staff:

Add a field on sign-in sheet so visitors can include their contact information.

  • Continue surveillance testing for staff regardless of vaccination status
  • Complete N-95 Fit Testing for all staff
  • Review PINs 21-17-ASC and 21-17.1-ASC for new guidance regarding visitation, communal dining, etc.
LPA requested updated copy of LIC500, Administrator certificate and Surety bond.
No deficiencies cited during this inspection
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE: DATE: 05/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/27/2021
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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