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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486801219
Report Date: 09/28/2021
Date Signed: 10/04/2021 09:07:24 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:MENDOZA CARE HOME IIIFACILITY NUMBER:
486801219
ADMINISTRATOR:JOSEPHINE MENDOZAFACILITY TYPE:
740
ADDRESS:241 LEXINGTON DR.TELEPHONE:
(707) 553-2580
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY:6CENSUS: 6DATE:
09/28/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:03 PM
MET WITH:Josephine MendozaTIME COMPLETED:
01:55 PM
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Licensing Program Analysts (LPA) Canela and Lopez arrived at this facility unannounced, to conduct an Annual Required infection control inspection. This inspection will focus on the Infection Control procedures and practices of this facility. LPAs met with Administrator Josephine Mendoza. There were 5 residents present at the facility.

LPA arrived at the facility and had temperature checked, but no health questions asked. Staff on duty were not wearing a face covering upon LPAs arrival, but staff wore one for the rest of the inspection. Facility was found to be clean and at a comfortable temperature. Resident bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguishers were found to be charged and inspected within the last 12 months. Toxins are stored and not accessible, although there were a couple of clorox wipe containers, but administrator put them away. There was an ample supply of hygiene products and paper products available for resident use.

Facility has submitted and received approval for a Covid Mitigation plan. Posters are in place at the entrance and throughout the building. The entrance area has a small table with hand sanitizer, thermometer and other items designated for visitors and staff before coming into work or visit. Facility has PPE supplies. Over the counter medication was observed in 1 of 6 residents bedrooms, not locked and accessible. Resident R1's is able to handle and keep their own over the counter medication but medication must be secured in a locked box to prevent access to resident R2 who has Dementia. Facility has a 30-day supply of medication. Residents do not typically wear masks inside the facility but have them available. Residents do however, wear masks while away from the facility.

During the tour LPAs observed the two backyard gates needing repair, so that the doors open and close properly. Resident R2's bedroom door also requires to be repaired as the sliding door is not properly opening. Due to LPA Canelas time restraint, LPA will need to return to issue citations for medications not locked and facility operating requirements for doors not properly working.

No citations issued at this time for todays inspection

SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:

DATE: 09/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2021
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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