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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
486801728
Report Date:
05/21/2024
Date Signed:
05/21/2024 10:13:49 AM
Document Has Been Signed on
05/21/2024 10:13 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, GLADYS
FACILITY TYPE:
735
ADDRESS:
163 DEVONSHIRE ST.
TELEPHONE:
(707) 656-6012
CITY:
VALLEJO
STATE:
CA
ZIP CODE:
94591
CAPACITY:
6
CENSUS:
4
DATE:
05/21/2024
TYPE OF VISIT:
POC
UNANNOUNCED
TIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:
Dinette Thompson
TIME VISIT/
INSPECTION COMPLETED:
10:30 AM
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LPA Leibert returns today in order to verify the deficiency noted at the visit of 5/7/2024 has been cleared. LPA Leibert noted that the refrigerated medication is secured in the kitchen refrigerator and that staff have been given refresher training. Deficiency cleared.
SUPERVISORS NAME
:
Carla Martinez
LICENSING EVALUATOR NAME
:
David Leibert
LICENSING EVALUATOR SIGNATURE
:
DATE:
05/21/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
05/21/2024
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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