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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803528
Report Date: 04/19/2024
Date Signed: 04/19/2024 05:16:25 PM


Document Has Been Signed on 04/19/2024 05:16 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. #1FACILITY NUMBER:
486803528
ADMINISTRATOR:MAGDALENA CASUGAFACILITY TYPE:
740
ADDRESS:985B OAKWOOD AVENUETELEPHONE:
(707) 648-2138
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY:6CENSUS: 4DATE:
04/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Magdalena "Nena" Casuga & Aileen BryantTIME COMPLETED:
02:41 PM
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Licensing Program Analyst (LPA) Araceli Canela arrived unannounced to conduct a Required - 1 Year inspection and met with, Aileen Bryant (S1) Co-Administrator and Administrator/Licensee, Magdalena Casuga. 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.

LPA toured facility and grounds and observed facility is at a comfortable temperature, with all exits free from obstruction. Facility has more than two days of perishable and one week of non-perishable foods and items were found to be stored properly. Facility has emergency water available. Water temperature was logged at 109.2 and within the required range of 105-120 degrees F. Fire Extinguisher was found to be charged, and serviced 1/30/2024. Smoke alarms and Carbon monoxide detector are operational. Facility has ceiling fire sprinklers that are serviced yearly. Facility last fire drill was conducted on 3/9/24.

LPA reviewed a resident and some staff files. Staff have the required training
CPR/1st aid expires 3/23/26 for staff S1. 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 has sensor motion Lights throughout the yard and in the facility hallways and/or night lights.

Administrator certificate for Magdalena "Nena" Casuga #6004227740 expires 11/6/2025.

Continue see LIC809-C
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:
DATE: 04/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/19/2024
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: 04/19/2024
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The yard has plenty of space, shade for activities and/or visitors and a table with chairs.

LPA discussed the Emergency Disaster Plan and Infection Control Plan.

Licensee/Administrator to submit the current following documents by 5/19/2024:

· 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

No citations issued during todays inspection.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:

DATE: 04/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2024
LIC809 (FAS) - (06/04)
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