486803431-5-12-2023-21-AS-DTOA-CRRQRB-20230512122341

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486803431
Report Date: 05/12/2023
Date Signed: 05/12/2023 12:23:51 PM

Document Has Been Signed on 05/12/2023 12:23 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 HOME		FACILITY NUMBER:	486803431
ADMINISTRATOR:	ALMOGELA, ZENAIDA B.		FACILITY TYPE:	740
ADDRESS:	406 MEADOWS DRIVE		TELEPHONE:	(707) 704-3713
CITY:	VALLEJO	STATE: CA	ZIP CODE:	94589
CAPACITY:	6	CENSUS: 3	DATE:	05/12/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:59 AM
MET WITH:	Gaylord Almogela, Administrator		TIME COMPLETED:	12:40 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 5/12/2023 Licensing Program Analyst (LPA) Tobola conducted an unannounced Annual Required – 1 yr. inspection for this facility and was greeted by staff Ana Montes and Administrator, Gaylord Almogela. The facility currently provides care for 3 residents, none of which are on hospice or a diagnosis of dementia. Residents were currently at day program at the time of visit. LPA arrived at the facility and had temperature checked and logged. LPA continued with a tour of the facility with Administrator and facility staff; facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was found to be last charged on 1/16/2023 at the time of the visit. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored and labeled as per regulations on this day at the time of the visit. Toxins are stored under the kitchen sink and in the garage and found to be secured. There was a supply of cleaners, hygiene products and paper products available for residents. All resident’s bedrooms have lighting & appropriate furnishings. Hot water measured at 118.9 and 119.4 degrees F which is within Title 22 regulations of 105 to 120 degrees F in faucets used by residents. Smoke and carbon monoxide detectors were tested and found to be in working order. Spot medication check was conducted and centrally stored medication records were found to be in order. Upon review of Guardian staff roster, LPA found that staff (S1) is not properly associated to the facility. Administrator stated that S1 was assisting as a volunteer but will review with Licensee of any fingerprint documentation for clearances. Staff training files were reviewed and found all staff to have proper 1st aid & CPR training on file. Continued onto LIC809-C

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:	DATE: 05/12/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2023

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: ALMOGELA'S BOARD AND CARE HOME	FACILITY NUMBER: 486803431
	VISIT DATE: 05/12/2023

NARRATIVE

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Infection Control:
All staff and residents have been vaccinated and received boosters with no reported or observed symptoms. Posters have been placed at the front door, and facility has a station at main entrance with a sign in, hand sanitizer and other items designated for visitors and staff. Staff are screened for temperature and symptoms on a daily basis and residents are screened based on changes of condition or symptoms.

Gaylord Almogela's Administrator certificate is valid through 3/22/2024.

LPA requested the following documents be sent to CCL by COB 5/26/2023:

LIC 308 Designated Facility Responsibility
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
LIC 9020 Register of Facility client’s/client’s
Copy of Administrator Certificate(s)

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties.

Civil Penalty is also being assessed in the amount of $100.00 due to one (1) staff not properly associated to the facility. Today's total assessment of $100.00 for each staff is for violation of Title 22 Regulation # 87355(e) & 87412(b)(3)

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:	DATE: 05/12/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/12/2023 12:23 PM - It Cannot Be Edited

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: ALMOGELA'S BOARD AND CARE HOME	FACILITY NUMBER: 486803431
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/12/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87355(e)

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 1 out of 1 individuals without proof of background clearance or association to the facility, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/13/2023
	Plan of Correction
1 2 3 4	Licensee agrees to agrees to immediately remove I1 from the facility until background clearance documentation is provided. In addition, Licensee is to properly associate staff (I1) to the faciltiy and provide CCLD with fingerprint clearance for I1, or identify a plan of compliance by POC date 5/13/2023.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:	DATE: 05/12/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2023

LIC809 (FAS) - (06/04)

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