Nene's Rest Home

Type of visit: Required - 1 Year

On 01/08/2026 at approximately 09:30AM, Licensing Program Analyst (LPA) Ali Deniz arrived unannounced to conduct 1-Year Required visit of this licensed Residential Care Facility for The Elderly (RCFE). LPA was greeted by Administrator, Mary Jane Miranda. Facility has an approved fire clearance and capacity for 6 non-ambulatory residents and has an approved hospice waiver for 3 individuals. Upon arrival, LPA was informed that there was only 1 (one) resident in care and 1 (one) staff member on-site. Facility is a 1 story building with 4 Resident bedrooms, 1 staff bedroom, 2 bathrooms, and common spaces. At approximately 10:05 AM, LPA reviewed the Facility's Staff Roster and found that all staff on-site were background cleared and associated to the facility per regulation. At approximately 11:05AM, LPA and Administrator toured the building and grounds which was found to be clean and in good repair. LPA observed all walkways and exits to be unobstructed. All notices that are required to be posted have been posted and are in a highly visible area. The amount of fresh and nonperishable foods is within regulation. Facility kitchen, refrigerators and freezers were clean, and food was stored properly. Toxins are stored in a locked housekeeping closet in the laundry room and under the kitchen sink. Water temperature measured 106.6 degrees F and 107.4 degrees F which is within regulation between 105- and 120-degrees F at faucets accessible to residents. Fire Extinguishers found to be last charged on 02/24/2025 at the time of visit. Carbon Monoxide and smoke detectors were present and in order. There was enough lighting in all common areas, resident rooms, and hallways. Medication is centrally stored and secure in a cabinet in the living room. Continued on LIC809-C page... Continued from LIC809 page... At approximately 2:05PM, LPA reviewed 1 resident record and found signed admission agreements, and physician's report on file. Administrator agreed to obtain resident’s missing files; Needs and Service Plan and TB test results (Technical Violation given). Medication records are thorough and contained physician's orders for each resident. At approximately 11:45AMM, LPA reviewed 2 staff records. All records did contain required documentation. LPA was presented with proof of current CPR & 1st Aid certification for the whole staff. Administrator Certificate is for Mary Jane Miranda #7017663740 expires 01/28/2027. LPA reviewed the facility emergency disaster plan. Facility has supplies enough to operate for more than 72 hours in an emergency. Administrator couldn’t find documentation of conducted disaster drills (Technical Advice Given). Updated copies of the following documents were requested for facility file and are to be submitted to CCL by due date of 01/20/2026: LIC 308 Designation Facility Responsibilities LIC 500 Personnel Summary LIC 9020 Register of Facility Client’s/Resident’s Copy/Proof of Updated Certificate of Liability Insurance No deficiencies were observed in the areas inspected, No citations were issued during today’s visit. Exit interview conducted. Copy of report provided to Licensee. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Jan 8, 2026

The state marks this report as 6 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Type of visit: Case Management - Incident

At approximately 1:30PM, Licensing Program Analysts (LPAs) Felias and Contreras arrived unannounced to conduct a Case Management - Incident Visit and met with Administrator, Mary Jane Miranda. The purpose of the visit was to follow up on an incident report that was self-submitted to Community Care Licensing (CCL). Incident Report 1: On 02/18/2025, CCL received an incident report. Per report, on 02/11/2025, Resident 1 (R1) was administered a medication that was for Resident 2 (R2). Report stated that facility monitored R1 for adverse effects. R1 was found to be in good health. Facility made all appropriate notifications per regulation. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Exit interview conducted. Copy of report, LIC809D (Deficiency Page), Confidential Names (LIC811), Plan of Corrections, and Appeal Rights discussed and provided to Administrator. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Mar 24, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Mar 25, 2025

87465 Incidental Medical and Dental Care: (a) A plan for incidental medical and dental care shall be developed...(4)The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: based on records reviewed, Licensee did not comply with the section cited above. Per incident report, Resident 1 was given Resident 2's medication. This is an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 24, 2025

Plan of correction: Licensee to submit certification that medication training will be conducted for facility staff. Certification to be submitted by due date of 03/25/2025. Training to be submitted by POC due date of 04/03/2025 and include Date, Training Topics, Job Role, Staff Names and Signatures.

Type of visit: Office

An Office Informal meeting was conducted today in the Santa Rosa Regional Office. The following individuals were present in the meeting: Licensing Program Manager, Victoria Bertozzi, Licensing Program Analysts, Caitlynn Felias and Star Stevenson, Licensee, James Miranda, and Staff Member, Dave Miranda. The purpose of today’s meeting was to address staffing concerns identified by the Department. During visits conducted on 01/17/2025 and 01/27/2025, LPAs Felias and Stevenson observed Administrator, Mary Jane Miranda, perform Administrator duties, caregiver duties, and personal child care duties for their two children. Review of facility documents showed that 2 of 3 residents are receiving hospice care, require nighttime supervision, and require assistance with feeding. 1 of 3 residents is required to be handfed. 1 of 3 residents is bedbound while 2 of 3 residents are non-ambulatory. All 3 residents would need assistance from staff to evacuate in the event of an emergency. 3 of 3 residents require assistance with the following activities of daily living: · Help with transferring · Bathing · Dressing · Incontinence care/toileting · Medication management In addition, interviews conducted with facility staff indicated that the Administrator also takes care of their two children, under the age of 8, during facility hours. The following areas were discussed during the meeting today: · Administrator Duties · Staffing and Care Needs of Residents Continued on LIC809C Continued from LIC809 Parties discussed facility's plan moving forward regarding staffing. Facility has hired an additional staff and has made changes to ensure residents' needs are met. Per discussion, Staff Member, Dave Miranda, will be providing childcare to alleviate the other caregiver of these duties as well as provide care on the NOC shift and throughout the day, as needed. Residents' on hospice are also being provided additional bathing during the week by the hospice agency. Department requested that an updated LIC500 be submitted to Community Care Licensing by due date of 02/24/2025. LPA will follow up with The Guardian regarding fingerprints of newly hired staff. No Deficiencies Cited during office meeting. Exit interview conducted. Copy of report discussed and provided to Licensee. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Feb 12, 2025

Type of visit: Case Management - Other

At approximately 12:45PM, Licensing Program Analysts (LPAs) Felias and Madaleno, arrived unannounced to conduct a Case Management - Other Visit and met with Administrator, Mary Jane Miranda. The purpose of today's visit is to follow up on a Type A deficiency and address staffing concerns that were identified during the facility's annual visit on 01/17/2025. During visit conducted on 01/17/2025, the Department cited the facility for not having current first aid/CPR certifications for 3 of 4 staff members. Licensee was to submit proof of scheduled training date to CCL (Community Care Licensing) by 01/18/2025. Administrator provided email proof to LPAs that CPR certificates were sent on 01/18/2025 to the Regional Office. Deficiency cleared during visit. LPAs also identified staffing concerns. During visit on 01/17/2025, Facility's personnel report indicated that there are 4 staff members employed at facility - the Licensee, the Administrator, 1 caregiver, and 1 on-call caregiver. During today's visit, LPAs were provided with an updated personnel report which indicated that 6 staff members were employed at the facility - the Licensee, the Administrator, 2 caregivers, and 2 on-call caregivers. LPAs reviewed resident files. Review of files indicated that 2 of 3 residents are on hospice. 2 of 3 residents also have a dementia diagnosis. Files showed that none of the residents require a two-person assist, but all 3 residents require at least one person for assistance with their activities of daily living. Interview with Administrator stated that they are the only full-time caregiver at this time, as the Licensee only comes to the facility once in a while and the other 4 caregivers are considered to be on-call. Administrator stated that they are the only full-time caregiver, and fulfill their Administrator duties later in the afternoon when it is less busy. LPAs discussed the importance of the Administrator being able to perform their Administrator duties as required separate from caregiver duties (deficiencies cited, LIC809D, regulation 87411(a) and 87405(a)). Per discussion with Administrator, their husband, Dave Miranda, will be taking over as Administrator of the facility, and they will become a full-time caregiver. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Exit interview conducted. Copy of report, LIC809D (Deficiency Page), Plan of Corrections, and Appeal Rights discussed and provided to Administrator. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Jan 27, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Jan 28, 2025

87411(a) Personnel Requirements – General Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not met as evidenced by: Based on interview and file review, Licensee did not comply with the section cited above and ensure facility is sufficiently staffed. 2 of 3 residents are on hospice with dementia and 3 of 3 residents need assistance with ADLs. Administrator performs caregiving duties full-time. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jan 27, 2025

Plan of correction: Licensee to submit self-certification email stating that they will enroll in administrator certification course to become the new administrator by POC due date 01/28/2025.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87405(a) · Plan of correction due date: Feb 6, 2025

87405 Administrator - Qualifications and Duties: (a) All facilities shall have a qualified and currently certified administrator...& permit adequate attention to the management & administration of the facility. This requirement was not met as evidenced by: Based on interview and file review, Licensee did not comply with the section above & ensure facility is sufficiently staffed. 2 residents are on hospice with dementia & 3 of 3 residents need assistance with ADLs. Administrator performs caregiving duties full-time. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jan 27, 2025

Plan of correction: Licensee to provide CCL an update regarding Administrator certification for Staff Member, Dave Miranda. Update to be provided by POC due date of 02/06/2025.

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs), Stevenson and Felias arrived unannounced at Nene's Rest Home for the purpose of conducting a Required 1 year inspection. LPAs were greeted at the door by Administrator, Mary Jane Miranda, and was granted access into the facility. LPAs toured facility with Administrator and observed that the facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Fire Extinguishers were found to be last charged on February 2024. All smoke detectors and carbon monoxide detectors were tested and found to be operational during the inspection. First aid kit was inspected and found to be appropriate during the inspection. Facility sinks were measured at 137.1F, 135.5F, and 126.5F which is out of compliance with Title 22 Regulation (deficiency cited, LIC809D, regulation 87303(e)(2)). LPAs discussed with Administrator about placing warning signs at sinks that are above 125F. There was sufficient perishable and non-perishable foods located in the kitchen. There are special provisions made for individuals with special dietary needs. Food menu was presently available for viewing during the inspection. Medications were centrally stored and locked. Cleaning products and other toxins are located under the kitchen sink and in the laundry room that was locked and inaccessible to residents in care. There was a supply of cleaners, hygiene products and paper products available for residents. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present. Resident bedrooms had lighting and appropriate furnishing. LPAs reviewed staff files, resident files, and resident medication. LPAs reviewed 4 staff files. During review, LPAs observed that Staff Member 1 (S1) had current first aid/CPR certification. Staff Member 2 (S2) only had CPR certification but not first aid. Staff Members 3 and 4 (S3 and S4) did not have current first aid/CPR certification as required (deficiency cited, LIC809D, Health and Safety Code, 1569.618(c)(3)). During review of resident files, LPAs observed that 2 of 3 residents were missing updated Needs and Services Plans/LIC625. Resident files were shown to have updated hospice care assessments. LPAs discussed the importance of having a facility care plan separate from the hospice care plan assessment (technical advisory issued, LIC9102, regulation 87463(i)). Continued on LIC809C Continued from LIC809 During visit, Administrator informed LPAs that during nighttime there is not a designated staff member awake to assist residents. LPAs informed Administrator that they are required to have at least one night staff person awake and on duty based on the size of their facility and the residents they serve (technical advisory issued, LIC9102, regulation 87705(b)(2)). LPAs obtained a copy of facility's most current LIC500 (Personnel Report). Administrator Certificate for Mary Jane Miranda (701663740) is current with an expiration date of 01/28/2025. Review of Department's Administrator Certification list indicated that Administrator renewal application had been received as of 12/23/2024. LPAs and Administrator discussed hospice waiver increases and hospice waiver exceptions. LPAs requested the following documents to be sent: LIC 500- Personnel Report LIC 308- Designation of Responsibility LIC 400- Affidavit regarding Client Cash Resources LIC9020 Register of Residents Updated facility sketch Updated Emergency Disaster Plan (LIC 610E) Most up-to-date Liability insurance Control of Property Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Exit interview conducted. Copy of report, LIC809D (Deficiency Page), LIC9102 (Technical Advisories/Violations), Confidential Names (LIC811), Plan of Corrections, and Appeal Rights discussed and provided to Administrator. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Jan 17, 2025

The state marks this report as 6 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a require 1-year inspection utilizing the full CARE tool. LPA met with Administrator, MaryJane Miranda, and explained the purpose of the visit. Today's census is three residents in care with one resident on hospice services. Facility is licensed for six residents, hospice waiver of two. LPA observed each resident in their private rooms. LPA and Administrator conducted a tour of the interior and exterior of the facility. Areas toured included but not limited to: residents bedrooms, bathroom, kitchen, backyard, staff room/laundry room, and the common areas. LPA observed fire extinguisher to be serviced on 02/27/2023. LPA reminded Administrator to serviced the extinguisher annually to ensure it is in working condition. LPA observed facility to have the required poster of Long Term Care Ombudsman and Community Care Licensing posted in a conspicuous space. LPA observed Administrator Certificate to be current with expiration date of 01/28/2025. LPA observed facility to have 2+ days of perishable and 7+ days of nonperishable foods. LPA conducted a file review of R1, R2, R3, S1 and S2. LPA observed no annual training present for S1 and S2's file. LPA is requesting a copy of LIC 308 and LIC 500 to be submitted to LPA Yang via email by February 2, 2024. LPA obtained a copy of liability insurance. During today's visit, LPA completed the care inspection tool and deficiency was observed. Please see LIC809-D. Exit interview conducted, a copy of the report and appeal rights was provided.the state’s words, verbatim · CDSS document, Jan 27, 2024