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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286804070
Report Date: 01/19/2023
Date Signed: 01/19/2023 01:57:41 PM


Document Has Been Signed on 01/19/2023 01:57 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: 3DATE:
01/19/2023
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
12:27 PM
MET WITH:Sasha Smith, Lead StaffTIME COMPLETED:
02:15 PM
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On 1/19/2023, Licensing Program Analyst (LPA) Tobola conducted an unannounced post-licensing inspection to this facility and was greeted by Lead Staff Sasha Smith. Administrator, Charmaine Mendaros was contacted by phone and notified of the visit. Facility currently has 3 residents in care one (1) of which who is on hospice and some of which with a diagnosis of dementia.

LPA toured the facility with Lead Staff and facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Fire Extinguisher was found to be purchased within the last year, LPA advised facility to contact Fire Department within the year to prepare for the upcoming annual visit. Carbon monoxide detectors were connected, tested and found to be in working order. LPA tested smoke alarms and all alarms in bedrooms were interconnected and in working order. LPA however observed one smoke alarm located in the living room in need of repair.

Toxins are stored in a locked cabinet in the kitchen and laundry room and under the kitchen sink both of which were kept secured. There was a supply of cleaners, hygiene products and paper products available for residents. The bathroom designated for residents at the facility were supplied with individual paper towels; hand soap dispenser was available. All 3 residents' bedrooms have lighting & appropriate furnishings. LPA conducted a file review for staff and found one staff (S1) without proper CPR & 1st Aid Certification on file. Licensee agrees to review and update all staff 1st Aid & CPR certification. Licensee is to provide proof of updated training certification for staff S1 to CCLD by POC date 1/25/2023. Medications are centrally stored in a locked cabinet in the facility dining room.

Continued onto LIC809-C
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic TobolaTELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:
DATE: 01/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/19/2023
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: AGING IN THE BAY 3
FACILITY NUMBER: 286804070
VISIT DATE: 01/19/2023
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During the inspection LPA found that two auditory alarms located at the exit doors in residents (R1) and (R2) bedrooms to be on the off position. LPA explained to staff that auditory alarms at exits must remain on when providing care to residents with dementia. Auditory alarms where immediately turned on, tested and in working order.

LPA issued technical violations and provided technical assistance with Administrator and Lead Staff.

No deficiencies cited during today's visit.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic TobolaTELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:

DATE: 01/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2023
LIC809 (FAS) - (06/04)
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