<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486801728
Report Date: 10/08/2021
Date Signed: 10/12/2021 09:51:01 AM

Document Has Been Signed on 10/12/2021 09:51 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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:GLAJAN CARE, INC.FACILITY NUMBER:
486801728
ADMINISTRATOR:MILES, GLADYSFACILITY TYPE:
735
ADDRESS:163 DEVONSHIRE ST.TELEPHONE:
(707) 656-6012
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY: 6CENSUS: 4DATE:
10/08/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Goldie WashingtonTIME COMPLETED:
12:03 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) A. Canela 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. LPA met with care staff, Goldie Washington ; Gladys Miles or Keith Cooper were not available during the visit. There are currently 4 clients living in the facility and they receive services from North Bay Regional Center.
LPA arrived at the facility and observed a small table at the front area with hand sanitizer but there was no thermometer for staff to check temperature of any staff or visitors coming in to the facility. In addition, health questions were not asked or a sign in sheet. Facility was found to be at a comfortable temperature and understand all exits need to be free from obstruction. Upstairs bathroom tub will need to be cleaned as it appeared there was vomit on the tub. 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. LPA observed main refrigerator, pantry, two additional refrigerators down stairs and facility was reminded of nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days shall be maintained on the premisesCare.

Facility has submitted and received approval for a Covid Mitigation plan. LPA reminded facility they must follow their Mitigation Plan. Posters are in place at the entrance and throughout the building. The entrance area will need a thermometer, sign in sheet , questionnaire, and small covered garbage can. Facility has PPE supplies. Medications are secure and not accessible to clients. Facility has a 30-day supply of medication. Clients do not typically wear masks inside the facility but have them available. Clients however, wear masks while away from the facility. Staff put a mask during this visit, after LPA asked them to put a mask on. LPA provide latest PIN information and reminded facility of requirement to maintain track of all visitors vaccination status.

No citations issued.

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE: DATE: 10/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/08/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 6