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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804107
Report Date: 12/15/2022
Date Signed: 12/15/2022 12:02:28 PM

Document Has Been Signed on 12/15/2022 12:02 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:NIGHTINGALE CARE HOMES LLCFACILITY NUMBER:
496804107
ADMINISTRATOR:BOTONES, ANNA KARINAFACILITY TYPE:
740
ADDRESS:5161 OAK MEADOW DRIVETELEPHONE:
(415) 341-7649
CITY:SANTA ROSASTATE: CAZIP CODE:
95401
CAPACITY: 6CENSUS: 5DATE:
12/15/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
08:12 AM
MET WITH:Anna Botones (Applicant)TIME COMPLETED:
12:17 PM
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Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct Pre-Licensing Inspection and Component lll due to a change of ownership and was greeted by staff Cassie Guerrero. Current licensee Alain Serkissian and Applicant Anna Botones were contacted, but Applicant was not able to come to the facility due to her residency is a distance away from the facility, but was available by phone and gave authorization for staff to sign the report. LPA requested a written plan from Applicant to address how they will ensure that Applicant spends a reasonable amount of time in the facility, resident's care needs will be met in case of an emergency and Community Care Licensing inspections.

Currently, there are five clients in care. Facility has a Dementia Care Plan approved to care for residents with dementia care needs. No residents in hospice. Facility is a single story residence and has 5 bedrooms for residents in care. The fire clearance for 6 non-ambulatory residents was granted 11/1/2022 by Sonoma County Fire Department. LPA to follow up with CAB regarding Fire Clearance, it was observed a storage room located in the left side of the facility locked pool and it is under construction. LPA inquired with Applicant and Licensee about required permits prior to construction, but it was revealed that the facility does not have the required permits and storage room is not in the Fire Clearance. LPA/Staff initiated a tour of the facility at 9:20 am and made the following observations: Facility was a comfortable temperature and passageways were free from obstructions. Resident rooms were furnished per regulation. Linens were in good repair. Bathrooms had required bath mats and grab bars. There are enough dishes and pots and pans for cooking. Smoke alarms and carbon monoxide detector were tested and operational at time of inspection. Auditory alarms were functional at time of inspection. Required postings were observed. First aid kit with manual was observed. LPA/lead staff observed cameras located in three locations in the common areas. Per Administrator, the cameras are not working at this moment, but they are planning to install their own cameras in the same locations. Applicant agreed to update the facility plan of operation and admission agreement to inform family of video surveillance and submit an exception request to licensing.
Continues on LIC809C...
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 12/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/15/2022
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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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: NIGHTINGALE CARE HOMES LLC
FACILITY NUMBER: 496804107
VISIT DATE: 12/15/2022
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Continued from LIC809...

Deficiency observed by LPA and cited on current license #496803416: Fire extinguisher was last inspected 10/2021. Water temperature in resident's bathroom measured at 124 and 125.1 degrees F which is not within allowable range of 105 to 120 degrees F.

LPA will submit copy of the facility report to the Centralized Application Unit and inform of citations, fire clearance and hot water, LPA to conduct subsequent pre-licensing inspection after POC's are cleared, updated fire clearance and to complete Component III.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:

DATE: 12/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2022
LIC809 (FAS) - (06/04)
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