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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486801728
Report Date: 11/08/2022
Date Signed: 11/09/2022 01:14:48 PM

Document Has Been Signed on 11/09/2022 01:14 PM - 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:MILES, GLADYSFACILITY TYPE:
735
ADDRESS:163 DEVONSHIRE ST.TELEPHONE:
(707) 656-6012
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY: 6CENSUS: 4DATE:
11/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:33 PM
MET WITH:Dinette WhitfieldTIME COMPLETED:
03:34 PM
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Licensing Program Analyst (LPA) A. Canela arrived at this facility unannounced, to conduct an Annual Required- 1 YR infection control inspection. This inspection will focus on the Infection Control procedures and practices of this facility. This facility is licensed for 6 Ambulatory clients.

LPA met with care staff, Dinette Thompson, Gladys Miles or Keith Cooper were not available during the visit, but gave permission for staff to sign report. 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. Facility was found to be at a comfortable temperature with all exits free from obstruction. Client bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguishers were found to be charged. Toxins are stored locked 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 premises.

Facility has submitted their Covid Mitigation plan. LPA reminded facility they must follow their Mitigation Plan. Posters are in place at the entrance and throughout the building. 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 know they must wear a mouth covering at all times when in the facility.

ntinue report see LIC809-C

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE: DATE: 11/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/08/2022
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: GLAJAN CARE, INC.
FACILITY NUMBER: 486801728
VISIT DATE: 11/08/2022
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LPA requested the following updated records to be submitted to Community Care Licensing by 11/30/2022

· LIC 308 Designation of Facility Responsibility
· LIC 500 Personnel Report (provided during visit)
· LIC 400 Affidavit Regarding Client/Resident Cash Resources
· LIC 402 Surety Bond, if applicable
· LIC 610D Emergency Disaster Plan (provided during visit)
· LIC 9020 Register of Facility Residents
· Copy of current, updated facility Sketch
· Copy Administrator Certificate


Exit interview conducted with Dinette Thompson, care staff.
No deficiencies cited during this inspection
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE:

DATE: 11/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2022
LIC809 (FAS) - (06/04)
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