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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486801728
Report Date: 11/14/2024
Date Signed: 11/18/2024 10:44:46 AM

Document Has Been Signed on 11/18/2024 10:44 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:GLAJAN CARE, INC.FACILITY NUMBER:
486801728
ADMINISTRATOR/
DIRECTOR:
MILES, GLADYSFACILITY TYPE:
735
ADDRESS:163 DEVONSHIRE ST.TELEPHONE:
(707) 656-6012
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY: 6CENSUS: 3DATE:
11/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:59 PM
MET WITH:Keith CooperTIME VISIT/
INSPECTION COMPLETED:
04:05 PM
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On 11/14/2024, Licensing Program Analyst (LPA) A. Canela conducted an unannounced Annual Required – 1 yr. Inspection for this facility. LPA arrived and no one was home, LPA waited for Administrator, Keith Cooper to arrive with client C2. The facility currently provides care for 3 clients, two of which were attending day program or on outings. LPA toured the facility with Administrator. Client’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was found to be last charged on 7/8/2024. Smoke and carbon monoxide detectors were found throughout the facility, and in working order. Food stored in the kitchen refrigerator were stored properly as per regulations on this day at the time of the visit. Water at faucets accessible to clients was measured between 105 and 120 degrees F as per Title 22 regulation.

LPA continued with a tour of the backyard and outside parameters and found both emergency exits along the sides of the home to be unobstructed. Medications are stored in a designated lockbox containers located in the kitchen area and found to be secured. A spot medication count was conducted for clients and found to be in order, facility uses a pharmacy that provides individual packets of Medication Administration Records, from the pharmacy and includes prescription numbers, administration orders and start times all of which were in order. Cleaning supplies and other toxins are safely stored in locked closet or cabinets.
Client and staff files are locked in cabinet. LPA reviewed client files and were found complete. Staff have proof of CPR/1st Aid certificates expiring 8/29/2025. Keith Cooper

Continue report see LIC809-C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE: DATE: 11/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/14/2024
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: GLAJAN CARE, INC.
FACILITY NUMBER: 486801728
VISIT DATE: 11/14/2024
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Licensee/Administrator to submit the below documents to LPA, by 12/14/2024.

· LIC 308 Designation of Facility Responsibility
· LIC 500 Personnel Report-
· LIC 400 Affidavit Regarding Client/Resident Cash Resources
· LIC 9020 Register of Facility Residents
Surety Bond and Administrator certificate.



No citations issued during todays inspection.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE:

DATE: 11/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2024
LIC809 (FAS) - (06/04)
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