486803789-10-2-2023-21-AS-JNAA-CW8RBR-20231002125311

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486803789
Report Date: 10/02/2023
Date Signed: 10/02/2023 12:53:25 PM

Document Has Been Signed on 10/02/2023 12:53 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:	TEJADA CARE HOME LLC		FACILITY NUMBER:	486803789
ADMINISTRATOR:	MENDOZA, JOSEPHINE G		FACILITY TYPE:	740
ADDRESS:	1440 OAKWOOD AVE		TELEPHONE:	(707) 853-2916
CITY:	VALLEJO	STATE: CA	ZIP CODE:	94591
CAPACITY:	6	CENSUS: 6	DATE:	10/02/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:58 AM
MET WITH:	Josephine Mendoza, Administrator		TIME COMPLETED:	01:00 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	Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to conduct a Required - 1 Year inspection and met with Administrator Josephine Mendoza. There are currently 6 residents in care. There were 2 staff at the time of inspection. This facility is licensed for 6 non-ambulatory residents, with hospice waiver approved for 2. There are currently no residents on hospice. LPA toured facility and grounds and observed all required signs posted in common areas. Infection control practices are present. Visitors are asked to sign in and face coverings and hand sanitizer are available. Facility has a 30-day supply of PPE. Facility has also submitted their Infection Control plan, which is a part of their Plan of Operation. Facility was found to be at a comfortable temperature of 71-72 F with all exits free from obstruction. Facility has at least two days supply of perishable and one week of non-perishable foods and items are stored properly. Fire Extinguishers were fully charged, and are due to be serviced next week. The grounds are clean and provide easy access for the residents to enjoy fresh air and many plants and fruit trees. The shed in the back yard is for storage of equipment only. The bedrooms are all furnished as required. Bathrooms were clean and sanitary and supplied with soap and paper towels, and non-skid mats and grab bars. The living room and sun room were equipped with comfortable chairs. The dining room was a hub of activity. Continued............

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill Nakagawa	TELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:	DATE: 10/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 2

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: TEJADA CARE HOME LLC	FACILITY NUMBER: 486803789
	VISIT DATE: 10/02/2023

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
26
27
28
29
30
31
32

.....Continued

During LPA's visit residents were helping with tasks, socializing with one another, eating a favorite meal, and laughing over shared stories.

LPA requested the following updated records to be submitted to Community Care Licensing (CCL) by 10/10/23:

· LIC 308 Designation of Facility Responsibility
· LIC 9020 Register of Facility Residents

Administrator will also provide copy of current Lease/Rental Agreement

Exit interview conducted with Josephine Mendoza.

No deficiencies cited during this inspection

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill Nakagawa	TELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:	DATE: 10/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2023

LIC809 (FAS) - (06/04)

Page: 2 of 2