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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216802050
Report Date: 06/01/2021
Date Signed: 06/01/2021 11:34:56 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:LUCAS VALLEY LODGEFACILITY NUMBER:
216802050
ADMINISTRATOR:ANGLADE, GREGOIREFACILITY TYPE:
740
ADDRESS:70 MOUNT TENAYA DRIVETELEPHONE:
(415) 377-4888
CITY:SAN RAFAELSTATE: CAZIP CODE:
94903
CAPACITY:4CENSUS: 4DATE:
06/01/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Administrator, Gregoire AngladeTIME COMPLETED:
11:45 AM
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Licensing Program Analyst(s), Farhaan Sarangi and Victoria Willis arrived unannounced to conduct an Required –1 Year inspection of the facility. LPAs were welcomed by administrator Gregoire Anglade - Administrator/Licensee. There is a total of 4 residents, 1 dementia resident. Currently the facility is under remodeling. Facility is repainting, installing new baseboards and installing new doors.

LPAs toured the facility on 06/01/2021 at 10:00 AM with Administrator/Licensee Gregoire Anglade; facility was found to be clean, and at a comfortable temperature. Construction materials located in living room were observed, but were not of risk to the residents in care. LPAs observed the outside backyard having hoses blocking the side yard and painting material. Outdoor pool was secured with a 5 foot metal fence that was properly latched and secured. Exits were not equipped with auditory devices. LPAs observed that one facility bedroom had a baby monitor. LPAs requested that be removed immediately. Staff bedrooms were furnished per regulation. Smoke detectors and carbon monoxide detectors were found to be operational during the visit. Fire extinguisher was last serviced in August 2019. Licensee will request a new servicing of the fire extinguishers. Water temperature in the facility was at 94.2 degrees. Licensee will submit a 7 day water log. Medications were found to be secured and locked. Hazardous toxins were found to be secured in locked below the kitchen sink. Facility has an ample supply of perishable and non-perishable foods.

In addition, LPAs advised facility to contact County Public Health and Community Care Licensing immediately if symptoms or COVID-19 + in the facility. Disaster Drills were conducted May 2021. LPAs reviewed the Mitigation Plan with the facility. Facility is in the process of obtaining N95 Fit Testing. Emergency Disaster plan was discussed with the Administrator.



No deficiencies were cited during today's Required 1- Year inspection. Exit interview was conducted and a copy of this report was emailed to the facility Administrator, Gregoire Anglade.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan SarangiTELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:

DATE: 06/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2021
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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