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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486801728
Report Date: 05/07/2024
Date Signed: 05/07/2024 10:25:25 AM

Document Has Been Signed on 05/07/2024 10:25 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: 4DATE:
05/07/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Dinette ThompsonTIME VISIT/
INSPECTION COMPLETED:
10:30 AM
NARRATIVE
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During the course of a complaint investigation, LPA Leibert noted that insulin and syringes were stored in the kitchen refrigerator in an unlocked container. The container had a combination lock and staff indicated they did not know the combination.
SUPERVISORS NAME: Carla Martinez
LICENSING EVALUATOR NAME: David Leibert
LICENSING EVALUATOR SIGNATURE: DATE: 05/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/07/2024
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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Document Has Been Signed on 05/07/2024 10:25 AM - It Cannot Be Edited


Created By: David Leibert On 05/07/2024 at 10:08 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: GLAJAN CARE, INC.
FACILITY NUMBER: 486801728

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/07/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/09/2024
Section Cited
CCR
870075(K)(1)

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870075(K)(1)Health Related Services. Medication shall be kept in a safe and locked place that is not accessible to persons other than employees..Based on observation, this requirement not met as evidenced by: LPA noted medication stored in unlocked container in the kitchen refrigerator.
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Administrator will secure the medication and provide refresher training to staff on topic of medication storage and will provide proof of safe storage and training to CCL by POC date in order to clear the deficiency.
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This posse an immediate risk to the health and safety on clients in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Carla Martinez
LICENSING EVALUATOR NAME:David Leibert
LICENSING EVALUATOR SIGNATURE:
DATE: 05/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/07/2024


LIC809 (FAS) - (06/04)
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