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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286804070
Report Date: 10/06/2022
Date Signed: 10/06/2022 01:47:05 PM


Document Has Been Signed on 10/06/2022 01:47 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:AGING IN THE BAY 3FACILITY NUMBER:
286804070
ADMINISTRATOR:MENDAROS, CHARMAINEFACILITY TYPE:
740
ADDRESS:1088 DONALDSON WAYTELEPHONE:
(510) 388-7352
CITY:AMERICAN CANYONSTATE: CAZIP CODE:
94503
CAPACITY:6CENSUS: 0DATE:
10/06/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:Applicant, Charmaine MendarosTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Erik Gonzalez Campos arrived unannounced on 10/06/2022 to conduct a prelicensing inspection. LPA met with applicant Charmaine Mendaros. This prelicensing is for an initial application. There are no residents currently in care.

Facility has a fire clearance for one ambulatory, two non ambulatory, and three bedridden residents. LPA toured building and grounds which were clean and in good repair. Facility has a total of five bedrooms, one of which is shared. Bathrooms were equipped with necessary grab bars and non-slip mats. Licensee plans to make modifications to bathroom. Licensure will be dependent on modifications. LPA observed necessary furniture except for chairs. Licensee plans to add chairs to resident bedrooms. Facility was a comfortable temperature. Exits and walkways were free from obstructions. Working auditory devices were observed on the doors. LPA and applicant discussed regulations concerning perishable and non-perishable food. There are locked storage units in the garage available for toxins. Medications will be stored in locked cabinets in the living room. Facility has a central storage area for resident and staff records. Operating smoke and carbon monoxide detectors were observed throughout the facility. Building has had a sprinkler system installed.

Applicant will obtain copies of LTCO and CCL complaint postings.

Comp III performed with applicant.

Exit interview conducted with applicant and a copy of this report emailed.

LPA will notify application unit to proceed with licensing pending modifications to bathroom. Applicant will submit pictures to LPA.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez CamposTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 10/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/06/2022
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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