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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803789
Report Date: 10/07/2024
Date Signed: 10/07/2024 03:53:00 PM


Document Has Been Signed on 10/07/2024 03:53 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 LLCFACILITY NUMBER:
486803789
ADMINISTRATOR:MENDOZA, JOSEPHINE GFACILITY TYPE:
740
ADDRESS:1440 OAKWOOD AVETELEPHONE:
(707) 853-2916
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY:6CENSUS: 5DATE:
10/07/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:20 PM
MET WITH:Josephine Mendoza, AdministratorTIME COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Araceli Canela arrived unannounced to conduct a Required - 1 Year inspection and met with Administrator, Josephine Mendoza. There are currently 5 residents in care. There were 2 staff at the time of inspection. This facility is licensed for 6 non-ambulatory residents, with6
LPA toured facility and grounds and observed all required signs posted in common areas. Facility was found to be at a comfortable temperature 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. The grounds are clean and provide easy access for the residents to enjoy fresh air. The shed in the back yard is for storage of equipment only. The bedrooms are all furnished as required. Bathrooms have non-skid mats and grab bars.
Fire Extinguishers were fully charged, and serviced on 9/11/2024. Carbon monoxide and smoke detectors were tested and operational during the visit. Water temperature measured within the required regulation of 105 to 120 degrees F.
Staff and resident files were reviewed and found complete and organized. Staff have the required training and proof of CPR/1st aid expiring 2025/2026. Administrator certificate for Josephine Mendoza #6018160740 expired on 7/9/2024, but was renewed on time and waiting for new certificate.

LPA received the following copies of updated forms during the visit:
· LIC 308 Designation of Facility Responsibility
· LIC 500 Personnel Report
· LIC 610 Emergency Disaster Plan
· LIC 9020 Register of Facility Residents
Copy of liability, Copy of current Lease/Rental Agreement good until 2028
Exit interview conducted with Josephine Mendoza.
No deficiencies cited during this inspection
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:
DATE: 10/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/07/2024
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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