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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 480109151
Report Date: 05/23/2023
Date Signed: 05/23/2023 12:21:59 PM

Document Has Been Signed on 05/23/2023 12:21 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:MC KINLEY CARE HOMEFACILITY NUMBER:
480109151
ADMINISTRATOR:MC KINLEY, BARBARAFACILITY TYPE:
735
ADDRESS:186 KEMPER STREETTELEPHONE:
(707) 557-2152
CITY:VALLEJOSTATE: CAZIP CODE:
94589
CAPACITY: 6CENSUS: 3DATE:
05/23/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:32 AM
MET WITH:Barbara McKinley, LicenseeTIME COMPLETED:
12:14 PM
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On 5/23/2023, Licensing Program Analyst (LPA) Tobola conducted an unannounced Annual Required – 1 yr. Inspection for this facility and was greeted by Licensee, Barbara McKinley. The facility currently provides care for three clients, none of which were present at the time of visit and attending day program.

LPA arrived at the facility and had temperature checked and logged. LPA continued with a tour of the facility with Licensee; facility was found to be clean and at a comfortable temperature. Client’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was found to be last charged on 5/20/2023 and was inspected and recharged during the visit. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were stored properly as per regulations on this day at the time of the visit. There was a supply of linens, hygiene products and paper products available for clients located in the hallway. All client’s bedrooms have lighting & appropriate furnishings with bedrooms well maintained and cleaned by staff. LPA conducted a file review for all clients and found documentation including medical assessments and individual program plans updated and in place. LPA conducted a review of all staff files and found staff to have updated 1st Aid & CPR certification and Direct Support Professionals training on file.

Facility conducts and records fire and disaster drills every month for all staff and clients. A storage located in the backyard was found to be secured. New outdoor fencing has been installed with no signs of damages. LPA found that the screen sliding door leading to the backyard is in need of replacing due to damage from client behavior. In addition, LPA observed a wall plug cover to be loose and in need of repair or replacing. Technical Violation issued.

Continued onto LIC809C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE: DATE: 05/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/23/2023
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: MC KINLEY CARE HOME
FACILITY NUMBER: 480109151
VISIT DATE: 05/23/2023
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Medication is found to be secured in locked filing cabinets located in the office area. A spot medication count was conducted for clients and found to be in order. The facility primarily utilized the Medication Administration Record (MAR) form indicating start and administering records of prescribed medications. LPA offered Technical Assistance requesting for staff to input start dates observed on the MAR onto the Centrally Stored Medication Records.


Licensee, Barbara McKinley's Administrator Certification 6023425735 is currently on the pending list and was received on 1/10/2023. In addition, Lead Staff, Shaheed Evans's Administrator Certification 6012483735 was received on 1/10/2023.

LPA requested the following documents be sent to CCL by COB 6/6/2022:

LIC 308 Designated Facility Responsibility
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
LIC 9020 Register of Facility Client’s/Resident’s


No deficiencies cited during today's visit.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:

DATE: 05/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2023
LIC809 (FAS) - (06/04)
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