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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803921
Report Date: 12/15/2022
Date Signed: 12/16/2022 11:29:32 AM


Document Has Been Signed on 12/16/2022 11:29 AM - 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:LODGE AT GLEN COVE, THEFACILITY NUMBER:
486803921
ADMINISTRATOR:SANDOVAL, GRACEFACILITY TYPE:
740
ADDRESS:140 GLEN COVE MARINA ROADTELEPHONE:
(707) 592-1157
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY:155CENSUS: 83DATE:
12/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:18 PM
MET WITH:Cathy Villarreal, Marketing DirectorTIME COMPLETED:
03:04 PM
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Licensing Program Analyst (LPA) Araceli Canela arrived unannounced to conduct a Required - 1 Year inspection and met with Cathy Villarreal, Marketing Director; Administrator, Grace Sandoval was not available during this visit. The annual inspection is focused on the Infection Control procedures and practices of this Residential Care Facility for the Elderly.

LPA toured facility and grounds with Cathy Villarreal, Marketing Director and observed some COVID-19 precaution signs posted in common areas to promote hand washing and physical distancing. LPA was screened for COVID-19 symptoms upon entrance to this facility. Visitors are screened for COVID-19 symptoms (including temperature check) upon arrival to the facility, but are failing to ensure hand hygiene, using hand sanitizer upon entrance to this facility. Infection control practices are present: entry procedures, face coverings, daily monitoring and temperatures checked for residents and staff, and 30-day PPE supply. High touched surface areas are disinfected daily. Bathrooms are equipped with liquid soap, paper towels and garbage cans and required Covid-19 hand washing posters. Facility submitted a Covid-19 mitigation plan, and infection control plan. Caregivers have completed PPE.
This facility is licensed to serve up to 155 residents. There are 3 floors being used, the first floor serves memory care residents and doors have 30 second delayed egress approved by the fire department. LPA toured the memory care area and tested the 30 second delayed egress door, which was able to open after the 30 seconds. The door maintains open with a small alarm until a staff comes over to turn it off and where the door is once again activated. The alarm is not loud enough to alert staff and the alarm does not send a signal to the front desk or to any staff. Unless staff are near by to hear the alarm, staff will not be alerted that a resident went out to the independent/assisted living of the facility. LPA consulted and requested the facility for a plan and how the facility will ensure staff are alerted if the door is activated to open, by close of business 12/16/2022. LPA went over requirements and failure to correct will result in citations being issued.
See LIC809-C for continuation of report.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:
DATE: 12/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/15/2022
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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: LODGE AT GLEN COVE, THE
FACILITY NUMBER: 486803921
VISIT DATE: 12/15/2022
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No fire safety hazards observed. Fire Extinguisher were found to be charged & serviced 12/13/2022. Floors have stair evacuation chairs. Facility has hard wire Smoke alarms, fire sprinklers that are serviced yearly and Carbon monoxide detectors.


LPA requested the following updated records to be submitted to Community Care Licensing by 1/10/2023

· LIC 308 Designation of Facility Responsibility
· LIC 500 Personnel Report
· LIC 610E Emergency Disaster Plan
· LIC 9020 Register of Facility Residents
· Copy of Liability insurance
· Copy Administrator Certificate



Exit interview conducted with Cathy Villarreal, Marketing Director.
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: 12/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2022
LIC809 (FAS) - (06/04)
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