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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 175001941
Report Date: 12/13/2022
Date Signed: 12/13/2022 11:12:45 AM

Document Has Been Signed on 12/13/2022 11:12 AM - 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: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:
12/13/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Cheryl Gambonini - LicenseeTIME COMPLETED:
11:15 AM
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On 12/13/2022 at approximately 9 AM License Program Analyst (LPA) Hansen arrived unannounced to conduct a Required 1 yr. Infection Control inspection to this facility. LPA was welcomed by Licensee – Cheryl Gambonini. There are 4 residents at facility, currently none on hospice or with dementia.

At approximately 9:15 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 and are in highly visible area. There was a sufficient supply of both perishable and nonperishable food as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations on this day at the time of the visit. Toxins are stored in a locked closet in the hallway. Water temperature in 2 residents bathrooms measured 111.7 degrees F. & 113.3 degrees F within regulation between 105 degrees F. and 120 degrees F. Fire extinguishers inspected were last charged on 8/17/2021 and has been given a technical assistance for being out of compliance date, although charged (see LIC 9102). Smoke detectors were tested and found to be in working order, but facility did not have carbine monoxide detectors, TA was given to be replaced by end of week (see LIC 9102) Facility has fire sprinklers throughout. There was enough lighting in all common areas, resident rooms, and hallways. Medication is centrally stored and secure in locked cart in dining room. Alarms are on all doors leading to outside.

Infection Control:
Facility has submitted a mitigation program plan and Infection Control Plan. 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.

Continued on LIC809-C...
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE: DATE: 12/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/13/2022
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: A NICE CARE HOME
FACILITY NUMBER: 175001941
VISIT DATE: 12/13/2022
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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 8/2022.

In addition, facility has a designated area for visitors which are being allowed for visits. Residents also have available Zoom, Facetime, and telephone calls when contacting with family members and others. Staff had all PPE training required on file and have obtained N-95 fit testing.



LPA Hansen reviewed Licensing Information System (LIS) with Licensee who stated that is corrected and updated at this time. 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 was presented with proof of current CPR & 1st Aid certification for staff.


Administrator Certificate is for Cheryl Gambonini 6007021740 Exp. 1/08/2023
All staff have received COVID booster vaccinations.
Technical Advisories given for Fire Extinguisher to be updated & Carbine Monoxide detector to be replaced

There were no deficiencies cited at this time.
LPA Hansen is requesting Licensee to update and submit the following documents to CCL by 01/13/2022:

LIC 308 Designated

LIC 309 Administrative Organization

LIC 500 Personnel Summary

LIC 610 Emergency Disaster Plan

LIC 9020 Register of Facility Resident’s

Copy of Administrator Certificate

Copy of Certificate of Liability Insurance

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

DATE: 12/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2022
LIC809 (FAS) - (06/04)
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