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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803526
Report Date: 05/04/2023
Date Signed: 05/04/2023 01:50:37 PM

Document Has Been Signed on 05/04/2023 01:50 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, 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: 1DATE:
05/04/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:13 AM
MET WITH:Aileen BryantTIME COMPLETED:
01:29 PM
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Licensing Program Analyst (LPA) Araceli Canela arrived unannounced to conduct a Required - 1 Year inspection and met with, Administrator, Magdalena Casuga and Aileen Bryant and toured the home. Aileen's Administrator certificate #6045024740 is active and expires 10/4/2023.

This facility is licensed for a total of 6 in which 4 of the residents may be non-ambulatory. There is currently 1 resident in the home. Facility does not have approval for bedridden, or Hospice. Resident R1 recently fell while visiting another home, was taken to emergency and received stitches on their head. R1 is doing well and sutures were removed. R1 is in the process of transferring to a sister facility.

LPA toured facility and grounds and observed 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 for the amount of residents living in the home. Fire Extinguisher was found to be charged, and serviced 3/2/2023. Smoke alarms and Carbon monoxide detector are operational. Facility last fire drill was conducted on 3/24/23. Medication is centrally stored and locked in the kitchen pantry.

Hot water temperature read 106 degrees F. which is within the required range of 105- 120 degrees f.

LPA reviewed resident file, and staff files. and found complete



Continue report see LIC809C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE: DATE: 05/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/04/2023
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: NENA & RAY'S GUEST HOME INC. #3
FACILITY NUMBER: 486803526
VISIT DATE: 05/04/2023
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LPA went over infection control plan. The back yard is fully fenced and no hazards observed.


Licensee/Administrator to submit the current following documents by 6/1/2023:
· LIC 308 Designation of Facility Responsibility
· LIC 500 Personnel Report
· LIC 400 Affidavit Regarding Client/Resident Cash Resources
· LIC 610E Emergency Disaster Plan
· LIC 9020 Register of Facility Residents
Infection Control Plan of Operation (If changes)
Copy of current Liability Insurance
Copy of current Lease Agreement
Current facility sketch



No Citations issued during this visit.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE:

DATE: 05/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2023
LIC809 (FAS) - (06/04)
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