216802050-3-10-2022-21-AS-FSAI-CCDPGL-20220310101830

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 216802050
Report Date: 03/10/2022
Date Signed: 03/10/2022 10:18:36 AM

Document Has Been Signed on 03/10/2022 10:18 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:	LUCAS VALLEY LODGE		FACILITY NUMBER:	216802050
ADMINISTRATOR:	ANGLADE, GREGOIRE		FACILITY TYPE:	740
ADDRESS:	70 MOUNT TENAYA DRIVE		TELEPHONE:	(415) 377-4888
CITY:	SAN RAFAEL	STATE: CA	ZIP CODE:	94903
CAPACITY:	4	CENSUS: 1	DATE:	03/10/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:50 AM
MET WITH:	Administrator, Gregoire Anglade		TIME COMPLETED:	10:25 AM

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Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced to conduct an Required –1 Year inspection of the facility. LPA was met a the door by Administrator, Gregoire Anglade. Administrator granted access into the facility.

LPA toured the facility on 03/10/2022 at 09:00 AM with Administrator/Licensee Gregoire Anglade; facility was found to be clean, and at a comfortable temperature. Outdoor pool was secured with a 5 foot metal fence that was properly latched and secured. Staff bedrooms were furnished per regulation. Smoke detectors and carbon monoxide detectors were found to be operational during the inspection. Fire extinguisher was last serviced in July 2021. Water temperature in the facility was within regulation of 105-120 degrees. There was a supply of cleaners, hygiene products and paper products available for residents. All bathrooms designated for residents in the common areas at the facility were supplied with individual paper towels and hand soap dispensers. Medications were found to be secured and locked. Hazardous toxins were found to be secured in locked below the kitchen sink. First Aid kit was observed in the medication cabinet. Facility understands that all beds should be outfitted with mattress pads as per Title 22 Regulations # 87307.

LPA requested that facility updates the current licensing forms below:

LIC 308 Designated

LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
LIC 610E-S Supplemental Emergency Disaster Plan for RCFE
LIC 9020 Register of Facility Client’s/Resident’s
Copy of Administrator Certificate
Copy of Certificate of Liability Insurance
(Report continued on LIC 809C)

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan Sarangi	TELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:	DATE: 03/10/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2022

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: LUCAS VALLEY LODGE	FACILITY NUMBER: 216802050
	VISIT DATE: 03/10/2022

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In addition, LPA advised facility to contact County Public Health and Community Care Licensing immediately if symptoms or COVID-19 + in the facility. Disaster Drills were conducted January 2022. LPA reviewed the Mitigation Plan with the facility. Facility got N95 Fit Tested. Emergency Disaster plan was discussed with the Administrator.

No deficiencies were observed or 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 DeBenedetti	TELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan Sarangi	TELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:	DATE: 03/10/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2022

LIC809 (FAS) - (06/04)

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