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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803824
Report Date: 07/22/2024
Date Signed: 07/22/2024 11:59:56 PM


Document Has Been Signed on 07/22/2024 11:59 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:CHENIN BLANC ASSISTED LIVINGFACILITY NUMBER:
486803824
ADMINISTRATOR:JONES, NIKIYAHFACILITY TYPE:
740
ADDRESS:5326 CHENIN BLANC PLACETELEPHONE:
(707) 208-6451
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY:4CENSUS: 2DATE:
07/22/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:11 PM
MET WITH:Nikiyah Jones, Licensee/AdministratorTIME COMPLETED:
03:12 PM
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Licensing Program Analyst (LPA), Araceli Canela arrived announced at Chenin Blanc Assisted Living for the purpose of conducting a Required-1 year inspection. This facility is licensed for (4) residents, three (3) may be non-ambulatory and has approval for one (1) bedridden and a Hospice waiver approved for one (1).

LPA toured the facility with Nikiyah Jones, Licensee/Administrator. The home was clean, organized, at a comfortable temperature, with all exits free from obstruction. Smoke detectors and carbon monoxide detector were tested and operational. The fire extinguishers located in the kitchen and hallway were charged and serviced on 08/01/2023. There are auditory alerts on exit doors. Water temperature is within the required range of 105 to 120 degrees Fahrenheit. Bathrooms have required non-skid surfaces and grab bars. Resident bedrooms are furnished per regulation. Cleaning products are stored locked. The Knives are stored in a locked box in the kitchen. There is adequate space and furniture on the patio for outdoor activities. There was more than a 7 day supply of non-perishable foods and the pantry contains plenty of food. Medications are centrally stored and locked in cabinet in the laundry area, close to residents rooms. Staff and resident files are locked in the office. Staff have current CPR/1st Aid that expires 6/14/2026. Administrator Certificate for Nikiyah Jones #6046254740 was renewed and awaiting certificate.

LPA requested the following updated forms:
· LIC 308 Designation of Facility Responsibility
· LIC 500 Personnel Report
· LIC 610E Emergency Disaster Plan
· LIC 9020 Register of Facility Residents
· Copy of current Lease/Rental Agreement or Property Tax document showing control of property and liability insurance· Infection Control Plan of Operation (If changes)No deficiencies were observed or cited
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:
DATE: 07/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/22/2024
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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