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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 175001941
Report Date: 12/21/2021
Date Signed: 12/21/2021 12:09:50 PM

Document Has Been Signed on 12/21/2021 12:09 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:A NICE CARE HOMEFACILITY NUMBER:
175001941
ADMINISTRATOR:GAMBONINI, CHERYLFACILITY TYPE:
740
ADDRESS:6784 CRUMP AVENUETELEPHONE:
(707) 274-9938
CITY:NICESTATE: CAZIP CODE:
95464
CAPACITY: 6CENSUS: 4DATE:
12/21/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Cheryl Gambonini - AdministratorTIME COMPLETED:
12:10 PM
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On 12/21/2021 at approximately 9:40 AM License Program Analyst (LPA) Hansen arrived unannounced to conduct a Required 1 yr. Infection Control inspection to this facility. LPA was welcomed by Administrator – Cheryl Gambonini. There are 4 residents at the facility with a hospice waiver for 2 although no residents are on hospice at this time.

At approximately 10:05 AM, LPA toured the building and grounds which was found to be clean and in good repair. LPA observed all walkways and exits to be unobstructed. All notices that are required to be posted have been posted and are in a highly visible area. LPA observed activity supplies for resident use. The amount of fresh and nonperishable foods is within Title 22 regulation of 2 days of perishable and 7 days of nonperishable. Facility kitchen was clean, and the refrigerator and freezer were clean, and food was stored properly. Toxins are stored in a locked closet in the hallway. Water temperature in 2 residents bathrooms measured 114.2 degrees F. & 116.7 degrees F within regulation between 105 degrees F. and 120 degrees F. Fire extinguishers inspected were last charged on 8/17/2021. Smoke detectors were tested and found to be in working order. Facility has fire sprinklers throughout. There was enough lighting in all common areas, resident rooms, and hallways. Medication is centrally stored and secure in a locked cart in the dinning room. Alarms are on all doors leading to outside.

Infection Control:
Facility has submitted a mitigation program plan that has been approved, on 9/10/2021. Posters have been placed at facility. Facility has PPE supply stored in locked hallway closet and are placed about the facility for use. Facility has a 30-day supply of medication for residents. Staff had all PPE training required on file. LPA informed Administrator to contact local public health to get staff N95 Fit Tested. LPA discussed with Administrator Cheryl Gambonini of current requirements that all visitors must either have tracking information of vaccine or negative COVID test results from the last 72 hrs prior to visiting.
Continued on LIC809-C...
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE: DATE: 12/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/21/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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: A NICE CARE HOME
FACILITY NUMBER: 175001941
VISIT DATE: 12/21/2021
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In addition, facility has a designated area for visitors outside on front porch. Residents also have available telephone calls when contacting with family members and others. LPA reviewed the facility emergency disaster plan with Administrator. Facility has a generator to supply power during an outage. The plan outlines evacuation routes, which are shown on facility sketch and has alternate meeting locations. Facility has supplies enough to operate for more than 48 hours in an emergency. Facility conducts drills twice a year with the last being 7/2020.


LPA reviewed Licensing Information System (LIS) with Administrator who stated that is corrected and updated at this time; no need to change any of the information. LPA advised facility to contact Local County Public Health and DSS/CCL Community Care Licensing immediately if symptoms or COVID-19 + in the facility. LPA discussed new PIN 21-44 that went into effect Nov. 30, 2021 regarding all staff needing to be fully vaccinated or have exemption letter on file with results of their weekly surveillance testing. Administrator informed LPA all staff and residents are fully vaccinated and have received their booster shots.

LPA was presented with proof of CPR & 1st Aid certification for staff.

There were no deficiencies cited at this time.

LPA Hansen is requesting Licensee to update and submit the following documents by 1/10/2021 to RPRO:

Copy of Administrator Certificate

Proof of Liability Insurance

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2021
LIC809 (FAS) - (06/04)
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