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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803431
Report Date: 05/17/2022
Date Signed: 05/17/2022 01:29:46 PM


Document Has Been Signed on 05/17/2022 01:29 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:ALMOGELA'S BOARD AND CARE HOMEFACILITY NUMBER:
486803431
ADMINISTRATOR:ALMOGELA, ZENAIDA B.FACILITY TYPE:
740
ADDRESS:406 MEADOWS DRIVETELEPHONE:
(707) 704-3713
CITY:VALLEJOSTATE: CAZIP CODE:
94589
CAPACITY:6CENSUS: 4DATE:
05/17/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Zenaida Almogela, LicenseeTIME COMPLETED:
01:35 PM
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Licensing Program Analyst (LPA) Tobola conducted an unannounced Case Management Visit and was greeted by Licensee, Zenaida Almogela. The purpose of the visit is to follow up on multiple SIR's and a 30-day eviction issued for resident R1 due to facility no longer being able to meet R1's needs.

Resident R1 had been transferred to Kaiser on three incidents from 3/30/2022 - 5/16/2022 due to observations of weakness and pain. Licensee is concerned of R1's ambulatory status as facility is not licensed to provide care for residents diagnosed as bedridden.

Licensee has submitted 30-day eviction request to CCLD and NBRC. LPA has previously spoken with Licensee requesting revisions. LPA received an updated and approved 30-day eviction with start date on 4/13/2022.

During the visit LPA observed R1 to be in bed and responded to LPA indicating that they were comfortable and doing well. LPA was informed by staff and Licensee that R1 has not had the strength to walk or stand but have not been provided a diagnosis for R1's ambulatory status from Kaiser. Licensee informed by Kaiser that since R1 is conserved by NBRC, the Licensee must contact NBRC for the Case Manager to submit a request to Kaiser to receive an update on R1's medical records. Licensee was informed by Kaiser that R1's conservator is also responsible for finding higher level of care or appropriate placement.

LPA Tobola and Licensee contacted NBRC Officer of the Day (O1) who is providing immediate emergency support for R1. LPA and Licensee were informed that O1 is working on obtaining an updated diagnosis for R1's ambulatory status as well as finding appropriate placement for R1.

No deficiencies cited during today's visit.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic TobolaTELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:
DATE: 05/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/17/2022
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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