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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803526
Report Date: 05/27/2021
Date Signed: 06/01/2021 02:45:05 PM

Document Has Been Signed on 06/01/2021 02:45 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:NENA & RAY'S GUEST HOME INC. #3FACILITY NUMBER:
486803526
ADMINISTRATOR:MAGDALENA A. CASUGAFACILITY TYPE:
740
ADDRESS:1123 LEGEND CIRCLETELEPHONE:
(707) 648-2138
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY: 6CENSUS: 2DATE:
05/27/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:25 AM
MET WITH:Administrator, Aileen BryantTIME COMPLETED:
01:45 PM
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Licensing Program Analyst (LPA) A. Canela arrived unannounced to conduct an Annual Required inspection and met with Backup Administrator, Aileen Bryant. The inspection is focused on the Infection Control procedures and practices of this facility.

Upon arrival, LPA observed that facility has a box on the floor just inside the entrance to the facility with hand sanitizer, a thermometer, disinfectant wipes and a sign in binder located in dining room. LPA requested facility to have a table set up at the entry point with all the required PPE and sign in book. Facility was reminded to train staff regarding Infection Control Practices, to ensure compliance with routine symptom screening at entry for all staff, resident or visitor. LPA suggested adding a field to the sign-in sheet where visitors can put in their contact information for record contact tracking purposes. Per conversation with Backup Administrator, they check the temperature of visitors and asks them screening questions, but had placed all PPE items in the box because a resident tries to take all PPE from the table. LPA conducted a walk-through of the facility and observed some Covid-19 posters throughout the facility that included hand-washing signs in each bathroom. LPA asked if 25% of staff are surveillance testing weekly and administrator stated they weren't because everyone is vaccinated. LPA confirmed that facility is checking resident and staff temperatures daily and documenting the information. LPA observed two residents in care watching television in their room, having lunch, watching television in dining area and/or doing activities. Two residents eat at the dining room table, the living room has furniture set up to allow for social distancing. LPA requested staff S2 to put her face mask back on, as she had removed for several minutes while in the kitchen/dining area. Facility staff have completed PPE training but have not yet been N-95 Fit tested.

Facility has submitted and received approval for a Covid Mitigation Plan. Backup Administrator was able to show LPA, 30 day supply of PPE; masks, gloves, hand sanitizer.

Continue report, see LIC809-C

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE: DATE: 05/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/27/2021
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: NENA & RAY'S GUEST HOME INC. #3
FACILITY NUMBER: 486803526
VISIT DATE: 05/27/2021
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LPA provided the following guidance to staff:
  • Add a field on sign-in sheet so visitors can include their contact information.
  • All staff must wear a face mask at all times, regardless of vaccination status.
  • Continue surveillance testing for staff regardless of vaccination status
  • Complete N-95 Fit Testing for all staff
  • Review PINs 21-17-ASC and 21-17.1-ASC for new guidance regarding visitation, communal dining, etc.



LPA requested updated copy of LIC500, Copy of Surety Bond, Copy of Administrator certificate and a completed Emergency Disaster Plan by 6/1/2021

No deficiencies cited during this inspection
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE:

DATE: 05/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2021
LIC809 (FAS) - (06/04)
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