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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486801728
Report Date: 11/02/2023
Date Signed: 11/02/2023 04:08:16 PM

Document Has Been Signed on 11/02/2023 04:08 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:
11/02/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:08 PM
MET WITH:Dinette Thompson, Lead StaffTIME COMPLETED:
04:15 PM
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On 11/2/2023, Licensing Program Analyst (LPA) Tobola conducted an unannounced Annual Required – 1 yr. Inspection for this facility and was greeted by Lead Staff, Dinette Thompson. Administrator, Keith Cooper was contacted and notified of the visit but was unable to meet for the inspection. The facility currently provides care for 4 clients, two of which were attending day program or on outings and two of which were present. LPA continued with a tour of the facility with staff. Client’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was found to be last charged on 11/17/2022. Smoke and carbon monoxide detectors were found throughout the facility, tested and found to be in working order. Food stored in the kitchen refrigerator were stored properly as per regulations on this day at the time of the visit. The facility staff were purchasing additional groceries during LPA's visit for restocking the food supply. LPA also observed staff providing take-out meals for clients. Water at faucets accessible to clients was measured at 102.5 degrees F which is not within Title 22 Regulations. LPA requested for Administrator to adjust and test water temperature to fall between 105 and 120 degrees F and submit corrections to CCLD. Technical Violation issued.

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. One shed located in the backyard for additional storage was found to be opened but did not contain any chemicals or items that constitute danger if accessible. 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. The facility is provided Medication Administration Records, from the pharmacy and includes prescription numbers, administration orders and start times all of which were in order. LPA observed knives located in the kitchen drawer potentially accessible to clients in care. LPA discussed possible option to more safely secure sharps and other similar items in a separate secured container or less accessible location to clients. Technical Violation issued. All clients attending day program are currently provided transport to and from the facility directly from the day programs. Continued onto LIC809-C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE: DATE: 11/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/02/2023
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: 11/02/2023
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Staff were observed to have a positive relationship with clients. The clients are offered various activities including shopping, walking around the neighborhood and visiting parks and other public outings. Clients were observed interacting and watching television with staff, in their rooms participating in independent activities for leisure. LPA was unable to conduct full file review for staff and clients and will return at a later date for an annual continuation visit.

Administrator, Keith Cooper's Administrator Certification 6044971735 is currently valid through 12/28/2023.

LPA requested the following documents be sent to CCL by COB 12/2/2023:

LIC 308 Designated Facility Responsibility
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
LIC 9020 Register of Facility Client’s/Resident’s
Liability Insurance
Proof of ownership
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2023
LIC809 (FAS) - (06/04)
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