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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 175001941
Report Date: 01/17/2025
Date Signed: 01/17/2025 07:13:18 PM

Document Has Been Signed on 01/17/2025 07:13 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:A NICE CARE HOMEFACILITY NUMBER:
175001941
ADMINISTRATOR/
DIRECTOR:		GAMBONINI, CHERYLFACILITY TYPE:
740
ADDRESS:6784 CRUMP AVENUETELEPHONE:
(707) 274-9938
CITY:NICESTATE: CAZIP CODE:
95464
CAPACITY: 6CENSUS: 4DATE:
01/17/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Cheryl Gambonini, AdministratorTIME VISIT/
INSPECTION COMPLETED:
07:30 PM
NARRATIVE
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At approximately 2:00 PM, Licensing Program Analysts (LPAs) Julie Florio and Ali Deniz arrived unannounced to conduct a required 1-year annual inspection and were greeted by staff. Cheryl Gambonini, Licensee/Administrator was contacted via telephone and arrived approximately 15 minutes later. Facility is a Residential Care Facility for the Elderly (RCFE) with four (4) residents in care, all of whom were present during today's inspection. Facility has a Dementia Care Plan, a Hospice waiver for three (3), and is approved for all non-ambulatory residents,.

At approximately 2:30 PM, LPAs initiated a tour of the facility with Administrator and observed the following: Facility is a one story home, was a comfortable temperature, and passageways were free from obstructions. Water temperatures in residents' bathrooms measured within the allowable range of 105 to 120 degrees F per Title 22 regulations. LPAs observed a supply of clean linens, and hygiene, incontinent care, and paper products available for residents. Residents' bedrooms were inspected and observed to have all the appropriate furnishings as outlined in Title 22 regulations. Cabinets containing cleaning supplies and other items that could pose a risk were locked. Facility has at least two days of perishable food and one week of non-perishable foods, as well as an emergency water supply. LPAs observed at least 15 instances of expired perishable and non-perishable food items, (see LIC809D). Medications were centrally stored and locked. There is a shaded seating area in the front and backyards with outdoor space for activities. LPAs observed another structure which was locked and is used as a bakery and the contents of which is mostly baking supplies and holiday decorations. Resident were observed engaged in community word games during inspection. Facility has an internet access device available for resident use. Facility has internet service available to residents in care and the telephone was tested an operational during inspection.

Continued on LIC809-C...
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE: DATE: 01/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/17/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: A NICE CARE HOME
FACILITY NUMBER: 175001941
VISIT DATE: 01/17/2025
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Continued from LIC809C...

Facility's 2 fire extinguishers were observed charged and were last serviced 12/2024. Smoke and Carbon Monoxide detectors were tested and operational during inspection. Facility conducts bi-annual disaster drills, and the most recent drill was conducted 01/2025. LPAs informed Licensee that drill shall be conducted on a quarerly basis moving forward, and Licensee agreed to bring the facility into compliance. LPAs observed the facility's infection control plan, first aid kit, PPE, emergency supplies, and facility has a generator for emergency preparedness. LPAs reviewed facility's emergency disaster plan last updated 1/2025.

At approximately 4:00 PM, LPAs conducted file review. Three (3) staff files and four (4) resident files were reviewed. All staff files reviewed were missing at least one (1) of the required documents, (See LIC809D). All staff have proof of required current First Aid certification. Four (4) of four (4) resident files reviewed were observed missing at least one (1) of the required documents, (See LIC809D).

Administrator states that most of the residents' family members coordinate residents' medical and dental appointments and transportation to and from visits. However, Administrator is available to assist with this as needed. Medications and medication records were inspeccted and the logs were observed to not be maintained in compliance with regulation, (see LIC809D). Facility does not handle P&I.

Updated copies of the following documents are to be submitted to CCL within 30 days of this visit:
  • LIC500 - Personnel Report (updated)
  • Proof of Liability Insurance (Updated)


Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Appeal rights were given. Exit interview conducted with Licensee whose signature on form confirms receipt of documents.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE:

DATE: 01/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2025
LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 01/17/2025 07:13 PM - It Cannot Be Edited


Created By: Julie Florio On 01/17/2025 at 06:46 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: A NICE CARE HOME
FACILITY NUMBER: 175001941

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/17/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above in ensuring that all personnel records are complete and up to date on all personnel, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/17/2025
Plan of Correction
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Licensee to submit a self certification that all personnel files are complete and up to date to CCL by POC due date 02/17/2025.
Type B
Section Cited
CCR
87555(b)(8)
General Food Service Requirements
(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in ensuring that there is no expired food in the facility which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/17/2025
Plan of Correction
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Licensee to submit a self certification that all food has been inspected and all expired items have been removed from the facility to CCL by POC due date 02/17/2025.
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:Bethany Moellers
LICENSING EVALUATOR NAME:Julie Florio
LICENSING EVALUATOR SIGNATURE:
DATE: 01/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/17/2025


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 01/17/2025 07:13 PM - It Cannot Be Edited


Created By: Julie Florio On 01/17/2025 at 06:46 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: A NICE CARE HOME
FACILITY NUMBER: 175001941

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/17/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(h)(4)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (4) All centrally stored medications shall be labeled and maintained in compliance with state and federal laws. No persons other than the dispensing pharmacist shall alter a prescription label.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above in ensuring that all medications were logged on each residents' centrally stored medication log which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/17/2025
Plan of Correction
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Licensee to submit a self certification that all residents' centrally stored medication log have been updated and currently and accurately reflect the medications on hand to CCL by POC due date 02/17/2025.
Type B
Section Cited
CCR
87506(a)
Resident Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above in ensuring that all resident records are complete and up to date which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/17/2025
Plan of Correction
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Licensee to submit self certification that all resident records are complete, accurate, and up to date to CCL by POC due date 2/17/2025.
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:Bethany Moellers
LICENSING EVALUATOR NAME:Julie Florio
LICENSING EVALUATOR SIGNATURE:
DATE: 01/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/17/2025


LIC809 (FAS) - (06/04)
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