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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804107
Report Date: 08/29/2024
Date Signed: 08/29/2024 11:16:58 AM

Document Has Been Signed on 08/29/2024 11:16 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:NIGHTINGALE CARE HOMES LLCFACILITY NUMBER:
496804107
ADMINISTRATOR/
DIRECTOR:
KASANDRA GUERREROFACILITY TYPE:
740
ADDRESS:5161 OAK MEADOW DRIVETELEPHONE:
(415) 341-7649
CITY:SANTA ROSASTATE: CAZIP CODE:
95401
CAPACITY: 6CENSUS: 5DATE:
08/29/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:50 AM
MET WITH:Kasandra Guerrero (Administrator)TIME VISIT/
INSPECTION COMPLETED:
11:28 AM
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Licensing Program Analyst (LPA) Cuadra arrived to conduct an unannounced Annual Required inspection and met with Administrator, Kasandra Guerrero. Annual fees are current. Contact information reviewed.

LPA/Administrator initiated a tour of the facility at approximately 9:15am and made the following observations: Facility was a comfortable temperature and passageways were free from obstructions. Resident rooms were furnished per regulation. Extra linens and hygiene products were available. Bathrooms have required grab bars and bath mats. Water temperature in resident bathroom read at 111.7 and 111.7 F which is within acceptable range of 105F and 120F. Toxins are located in a locked closet in one of the dining room areas. Swimming pool located in the backyard was locked with a padlock and inaccessible to residents in care. Medication is centrally stored in a locked closet near the kitchen. Fire extinguishers were last inspected December, 2023. Smoke alarms and carbon monoxide detector were tested and operational at time of inspection. Auditory alarms were functional at time of inspection. Last disaster drill conducted on 7/13/24. The facility have two days of perishable and one week of non-perishable food available. However, LPA/Administrator discussed the benefits of having an ample supply of food. Per Administrator, today is shopping day and they were heading to the store when LPA arrived. Required postings were observed.

LPA initiated file review at approximately 10:00am. Five resident files and three staff files were reviewed. Staff have active CPR and First Aid certificates and training hours required. One out of three staff LIC503 did not include TB test results (technical violation issued). Five residents have current care plans and medical assessments. Administrator Certificate for Kasandra Guerrero, 6067815740 expires 9/25/25. Medication and medication records were reviewed. During LPA's visit, residents were observed engaged in music activities.

Administrator provided copies of the following: (LIC500) Personnel Report, (LIC308) Designation of administrative responsibility, copy of liability certificate and control of property.
No deficiencies cited during this inspection. Exit interview was conducted with Administrator and a copy of this report was given.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 08/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/29/2024
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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