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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486800936
Report Date: 12/15/2022
Date Signed: 12/15/2022 11:50:18 AM

Document Has Been Signed on 12/15/2022 11:50 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:MC KINLEY CARE HOME #2FACILITY NUMBER:
486800936
ADMINISTRATOR:MCKINLEY/EVANSFACILITY TYPE:
735
ADDRESS:336 SAWYER STREETTELEPHONE:
(707) 557-4053
CITY:VALLEJOSTATE: CAZIP CODE:
94589
CAPACITY: 6CENSUS: 6DATE:
12/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:16 AM
MET WITH:Aliyah Evans, Lead StaffTIME COMPLETED:
12:00 PM
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On 12/15/2022, Licensing Program Analysts (LPA) Tobola conducted an unannounced Annual Required – 1 yr. Infection Control inspection for this facility and was greeted by Lead Staff, Aliyah Evans. Administrator, Barbara McKinley was contacted and arrived later in the visit. The facility currently provides care for 6 clients, four of which where present and two of which were on an outing with the Administrator.

LPA arrived at the facility and had temperature checked and logged. LPA continued with a tour of the facility with Lead Staff; facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Client’s bedrooms, common areas, kitchen & food storage areas were inspected. The fire extinguisher located near the facility dinning area was found to be last charged on 8/5/2022 at the time of the visit. Smoke and carbon monoxide detectors were tested throughout the facility and found to be in working order. There was a sufficient supply dishes, silverware and both perishable and nonperishable foods for clients in care. Food was also found to be stored properly as per Title 22 Regulations with a variety of nutritious food options .

Toxins, tools and other cleaning supplies are stored and located in the facility garage and outdoor shed which were both found to be secured. LPA was notified that the garage area is being renovated to serve as an office space. LPA Tobola requested for Administrator to notify CCL of completion and updated facility sketch. There was a supply of cleaners, hygiene products and paper products available for clients in their individual rooms and also provided when requested. All client’s bedrooms have lighting & appropriate furnishings. Backyard emergency exits were unobstructed and easily accessible.

Continued onto LIC809-C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE: DATE: 12/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/15/2022
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: MC KINLEY CARE HOME #2
FACILITY NUMBER: 486800936
VISIT DATE: 12/15/2022
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Infection Control:
Facility has submitted a infection control plan for review. Posters have been placed at the front door, and facility has a station in the staff office near facility entrance with a sign in sheet, hand sanitizer and other items designated for visitors and staff. Staff and clients are screened for temperature and symptoms on a daily basis.

No deficiencies cited during today's visit.


Barbara McKinley's Administrator Certification 602345735 expires on 12/15/2022. LPA did not observe Barbara McKinley's in the pending certification list and informed Administrator to update new certification immediately.

LPA requested the following documents be sent to CCL by COB 12/29/2022:

LIC 308 Designated Facility Responsibility
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
LIC 9020 Register of Facility Client’s/client’s
Copy of Administrator Certificate(s)
Copy of Liability Insurance
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:

DATE: 12/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2022
LIC809 (FAS) - (06/04)
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