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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803431
Report Date: 06/25/2024
Date Signed: 06/25/2024 04:38:53 PM


Document Has Been Signed on 06/25/2024 04:38 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: 2DATE:
06/25/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:17 PM
MET WITH:Ana Montez, House ManagerTIME COMPLETED:
04:45 PM
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On 6/25/2024, Licensing Program Analyst (LPA) Tobola conducted an unannounced Annual Required – 1 yr. inspection for this facility and was greeted by House Manager, Ana Montez. Licensee, Gaylord Almogela was contacted and notified of the visit. The facility currently has 2 residents admitted, none of which with a diagnosis of dementia. The facility is currently with a COVID positive case. LPA had conducted only the physical facility portion of the inspection due to COVID safety precautions.

LPA continued with a tour of the facility with House Manager. Facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Resident common areas, kitchen & food storage areas were inspected. Fire Extinguishers found to be charged on 1/8/2024. Smoke and carbon monoxide detectors found throughout the facility, were tested and found to be functioning. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations, with food stored in the kitchen refrigerator found to have appropriate coverings.

Cleaning supplies and other toxins are safely stored in locked cabinets in the garage and under the kitchen sink, all of which were secured upon inspection. Sharps and other kitchen supplies that could pose danger if available to residents were found secured. There was a supply of hygiene products and paper products available for residents. Water at faucets accessible to residents were measured at 107.4 degrees F which is within regulation. There is one primary emergency exit located in the backyard which were found to be unobstructed. There is an outdoor patio with shade and large outdoor space for residents. No deficiencies cited during today's visit. LPA to continue annual for facility file and medication review at a later date.

Licensee, Zenaida Almogela's Administrator Certificate 7034417740 is valid through 10/18/2025.
LPA requested the following documents be sent to CCL by COB 7/25/2024:

LIC 308 Designated Facility Responsibility LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan Liability Insurance
Control of Property/Rental Agreement
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic TobolaTELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:
DATE: 06/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/25/2024
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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