486803528-4-28-2023-21-AS-ACAA-CRBUX7-20230428155752

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486803528
Report Date: 04/28/2023
Date Signed: 04/28/2023 03:59:28 PM

Document Has Been Signed on 04/28/2023 03:59 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. #1		FACILITY NUMBER:	486803528
ADMINISTRATOR:	MAGDALENA CASUGA		FACILITY TYPE:	740
ADDRESS:	985B OAKWOOD AVENUE		TELEPHONE:	(707) 648-2138
CITY:	VALLEJO	STATE: CA	ZIP CODE:	94591
CAPACITY:	6	CENSUS: 4	DATE:	04/28/2023
TYPE OF VISIT:	Case Management - Annual Continuation	UNANNOUNCED	TIME BEGAN:	02:31 PM
MET WITH:	Magdalena "Nena" Casuga and Aileen Bryant		TIME COMPLETED:	04:17 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 6 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, of which one (R1) is out of the facility receiving rehabilitation services due to a recent hospitalization due to a hip fracture from a fall. 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. 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. Facility will send in copy of staff S1s who was recently hired health screening. LPA consulted regarding staff training that 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. #1	FACILITY NUMBER: 486803528
	VISIT DATE: 04/28/2023

NARRATIVE

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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.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.

Administrator and LPA discussed their 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

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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Document Has Been Signed on 04/28/2023 03:59 PM - 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: NENA & RAY'S GUEST HOME INC. #1	FACILITY NUMBER: 486803528
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87355(e)(3)

Criminal Record Clearance

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on todays record review with adminiostrator, the licensee did not comply with the section cited above in 1 out of 4 staff, S1 who had proof of being fingerprint cleared but was accidentaly associated to the wrong facility, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/02/2023
	Plan of Correction
1 2 3 4	Facility has sent in required forms to Community Care Licensing to associate S1. Facility to send in written statement they understand regulation and how it will be followed.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: 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 appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2023

LIC809 (FAS) - (06/04)

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