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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803526
Report Date: 03/23/2022
Date Signed: 03/24/2022 11:22:15 AM

Document Has Been Signed on 03/24/2022 11:22 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: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:
03/23/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Aileen BryantTIME COMPLETED:
03:23 PM
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Licensing Program Analyst (LPA) Araceli Canela arrived unannounced to conduct a Required - 1 Year inspection and met with, care staff, Aileen Bryant and toured the home. The annual inspection is focused on the Infection Control procedures and practices of this Residential Care Facility for the Elderly. This facility is licensed for a total of 6 in which 4 of the residents may be non-ambulatory. There are currently 2 residents in the home.

LPA toured facility and grounds and observed COVID-19 precaution signs posted in common areas to promote hand washing. ovid precautions. LPA was screened for COVID-19 symptoms upon entrance to this facility. Visitors are said to be screened for COVID-19 symptoms upon arrival to the facility. Infection control practices present: entry procedures, mask wearing, daily monitoring and temperatures checked for residents and staff, and 30-day PPE supply. Facility to follow indoor visitation requirement of verifying and tracking COVID-19 vaccination or verify non-essential visitors have proof of a negative COVID-19 test. Facility states staff clean and disinfect the facility daily. Bathrooms are equipped with liquid soap and paper towels. Covid-19 Mitigation plan was reviewed 3/11/2021. Caregivers have completed PPE training and have been N-95 Fit tested.

In addition, facility was found to be clean at a comfortable temperature with all exits free from obstruction. Facility has at least two days of perishable and one week of non-perishable foods. Fire Extinguisher was found to be charged, and serviced 3/15/2022.

LPA requested facility to submit updated LIC9020, and LIC500 by 3/29/2022.

No citations issued during this visit.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE: DATE: 03/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/23/2022
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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