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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486801728
Report Date: 05/14/2024
Date Signed: 05/14/2024 10:11:26 AM

Document Has Been Signed on 05/14/2024 10:11 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:
05/14/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Dinette ThompsonTIME VISIT/
INSPECTION COMPLETED:
10:30 AM
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LPA Leibert arrives unannounced for the purpose of verifying training records and secured medications stemming from citation issued on 5/7/2024. Administrator had advised LPA that training was scheduled for yesterday at 4pm. However, LPA learned this date that the training has been rescheduled for this coming Thursday, 5/16. Therefore the POC date has been extended to 5/16. LPA inspected refrigerated medication and noted that the combination lock box has been replaced by a key locked box for the insulin.
SUPERVISORS NAME: Carla Martinez
LICENSING EVALUATOR NAME: David Leibert
LICENSING EVALUATOR SIGNATURE: DATE: 05/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/14/2024
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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