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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347001016
Report Date: 12/29/2021
Date Signed: 12/29/2021 11:51:43 AM

Document Has Been Signed on 12/29/2021 11:51 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, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:NELLE HOME PLACEFACILITY NUMBER:
347001016
ADMINISTRATOR:GIMON, IOANFACILITY TYPE:
740
ADDRESS:5340 NELLE PLTELEPHONE:
(916) 863-1201
CITY:FAIR OAKSSTATE: CAZIP CODE:
95628
CAPACITY: 6CENSUS: 3DATE:
12/29/2021
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:Auruta Gimon, Manager TIME COMPLETED:
11:50 AM
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a required annual. LPA met with manager, Auruta Gimon and Administrator, Ioan Gimon. LPA completed required COVID-19 testing protocols and confirmed the facility does not currently have any positive Covid-19 diagnoses. Additionally, LPA was screened per Covid-19 precautionary measures upon entering the facility. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N95 mask. Facility currently has (3) residents, none of whom are currently on hospice. (1) resident, who was on hospice, passed earlier this morning. LPA observed the mortuary representative arrive during the inspection and family members present also, wearing masks.

LPA and manager toured the interior of the facility, including (5) private resident rooms, resident bathrooms, kitchen, common areas and caregiver rooms. LPA observed it to be clean and in good repair. LPA observed various Covid posters throughout. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and manager completed the infection control domain and facility was found to be in compliance at this time. Inside temperature was observed to be 73* F. Fire extinguisher last serviced 1/12/2021- to be re-serviced by 1/12/2022. LPA observed sufficient 2+day perishable and 7+day non-perishable food. LPA observed paper towels, soap, sanitizer and trash cans with lids in the bathrooms as well as PPE supply. Sharps, toxins and medications are secured appropriately. LPA and Administrator discussed vaccination status of residents and staff as well as visitation protocols per PIN 21-40 issued 8/27/2021. Testing requirements also discussed. The facility has not had any prior/current Covid cases.

LPA was provided with a copy LIC500 and current liability insurance during today's inspection. There were no deficiencies observed during today's inspection. Exit interview. Copy of report provided to manager.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE: DATE: 12/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/29/2021
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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