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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803526
Report Date: 05/07/2024
Date Signed: 05/09/2024 11:28:53 AM

Document Has Been Signed on 05/09/2024 11:28 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/
DIRECTOR:		MAGDALENA A. CASUGAFACILITY TYPE:
740
ADDRESS:1123 LEGEND CIRCLETELEPHONE:
(707) 648-2138
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY: 6CENSUS: 0DATE:
05/07/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:45 AM
MET WITH:Nena Casuga, LicenseeTIME VISIT/
INSPECTION COMPLETED:
01:04 PM
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Licensing Program Analyst (LPA) Araceli Canela arrived unannounced to conduct a Required - 1 Year inspection and met with, co-licensee, Nena Casuga.

This facility is licensed for a total of 6 in which 4 of the residents may be non-ambulatory. There is currently no residents living in the home and there was no one available, Nena Casuga and Aileen Bryant arrived a few minutes later.

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. Fire Extinguisher was found to be charged, and serviced 3/24/2024. Smoke alarms and Carbon monoxide detector are operational. Medication will be centrally stored and locked in the kitchen pantry.

Hot water temperature read 107.1 and is within the required range of 105- 120 degrees f.

Licensee/Administrator to submit the current following documents by 6/1/2024:
· 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


No Citations issued during this visit.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE: DATE: 05/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/07/2024
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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