486803921-1-12-2021-21-AS-ACAA-BX886A-20210112211402

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486803921
Report Date: 01/12/2021
Date Signed: 01/12/2021 09:14:31 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME:	LODGE AT GLEN COVE, THE		FACILITY NUMBER:	486803921
ADMINISTRATOR:	KINDRED, NICHOLE		FACILITY TYPE:	740
ADDRESS:	140 GLEN COVE MARINA ROAD		TELEPHONE:	(707) 592-1157
CITY:	VALLEJO	STATE: CA	ZIP CODE:	94591
CAPACITY:	155	CENSUS: 0	DATE:	01/12/2021
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	Jason Reyes, Nichole Kindred		TIME COMPLETED:	04:54 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) A. Canela, conducted this Prelicensing inspection, on 1/12/2021 at approximately 1:15PM, and met with Licensee, Jason Reyes, Administrator Nichole Kindred, Marketing Director, Cathy Villareal and Maintenance Director, Jason Simon. Prior to entering LPA sanitized hands, took temperature and wore a face mask. Upon entrance to the facility, LPA was requested by facility to take temperature, complete questionnaire and hand sanitize as part of their Covid entrance procedure. LPA observed all staff wearing a face mask and hand sanitizing stations throughout. This facility is located at 140 Glen Cove Marina Road, near the Glen Cove Marina and has a total of 141 apartments. There are two floors in the facility and a ground floor, a fire clearance was granted on 12/22/2020 by the Vallejo Fire department for the total capacity requested of 155 residents, of which, 130 are nonambulatory and 25 bedridden. The applicant has submitted a hospice request that was granted for 25 residents, and a dementia care plan as part of the facility's plan of operation. The facility site consists of an assisted living building, which includes a memory care unit. LPA toured several areas in the building such as, a large activity room, movie room, spa/massage room, library, salon, family/resident dining unit, dining rooms for assisted living and dining room for memory care unit. The Memory care unit that has delayed egress, that was approved by the Fire Department which was tested and found in working order by LPA during the inspection. Memory care courtyard is within memory care building and doors lead to interior of memory care building. Memory care halls have soothing colors and detailed floors to assist residents, as well as large signs on walls to assist them. It also offers a sound and light interactive board for residents to engage in. This facility was recently constructed and offers several room plans in the assisted living area, such as a studio, 1 and 2 bedroom floor plans. Rooms have the required furnishings and bathrooms were equipped with the required safety bars and non-slip floors. Continue report see LIC809-C

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Araceli Canela	TELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:	DATE: 01/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2021

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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: LODGE AT GLEN COVE, THE	FACILITY NUMBER: 486803921
	VISIT DATE: 01/12/2021

NARRATIVE

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All rooms have the required smoke and carbon monoxide detectors. There are several fire extinguishers mounted throughout the facility and they were observed to be charged and serviced in September and December 2020. LPA toured the Kitchen area and observed it clean, Refrigerator and freezer temperature is within regulation. The facility also has fire sprinklers that will be serviced yearly. Water temperature was 116 degrees and within the required regulation of 105-120 degrees F. LPA was able to observe comfortable furnishings throughout the facility. The grounds were free of any apparent hazards, and exits were clear. No bodies of water. No firearms. LPA observed medication room for assisted living area, and a medication room in the memory care unit. Facility had emergency supplies to meet requirement for the 72 hour shelter in place. Postings noted to be current and in compliance with regulations.
There is a permanently placed large generator that in an emergency can run 3 hours. Facility has emergency supplies, including flashlights, first aid supplies, and other items as listed in the emergency plan/disaster plan. LPA observed three evacuation chairs at the top of all 2nd floor stairwells. LPA observed that the facility has an emergency disaster plan binder kept at the reception area, and staff have access to the binder and facility vehicle keys. Medications will be locked and inaccessible to residents in care- in medication rooms. Toxins/cleaners will be locked and inaccessible to residents in care. Facility has a large supply of Personal Protective Equipment (PPE) for use as needed. Facility has all Covid 19 policies/precautions in place. All postings were posted, and visible as required.
Component III orientation with Administrator Nichole Kindred was waived as Administrator has ran another sister facility and is aware of regulation.
Applicant is advised prior to any structural changes, facility may require CCL approval, fire clearance and inspection.

Pre-Licensing is complete and this facility has no apparent safety hazards and/or concerns observed.

LPA will forward a copy to the application unit in Sacramento; The application analyst will notify the applicant the status of the application

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Araceli Canela	TELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:	DATE: 01/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2021

LIC809 (FAS) - (06/04)

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