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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486803921
Report Date: 07/02/2025
Date Signed: 07/02/2025 11:04:53 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/30/2025 and conducted by Evaluator Elias Magdaleno
COMPLAINT CONTROL NUMBER: 21-AS-20250630103354
FACILITY NAME:LODGE AT GLEN COVE, THEFACILITY NUMBER:
486803921
ADMINISTRATOR:JASMINE SEIFFERTFACILITY TYPE:
740
ADDRESS:140 GLEN COVE MARINA ROADTELEPHONE:
(707) 653-4728
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY:155CENSUS: 141DATE:
07/02/2025
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:JASMINE SEIFFERT, AdministratorTIME COMPLETED:
11:15 AM
ALLEGATION(S):
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Residents room is not clean and sanitary
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Magdaleno arrived unannounced to initiate a Complaint Investigation and deliver findings regarding the above allegations and met with Administrator, Jasmine Seiffert.

During this investigation LPA made observations, conducted interviews, and reviewed records.

Residents room is not clean and sanitary – Complainant alleges that upon entry to Resident (R1) room “we were met with a smell or urine and other bodily fluids that smelt like they have been lingering for a while. On top of that there was trash all over the floor, no beds were made, there was trash and dirty dishes in the sink that looked like they have been there for a while”. During this investigation LPA made observations, conducted interviews, and reviewed records. R1 room was observed to be as described above with a strong smell of urine throughout. Interviews with staff indicate that R1 has continuously refused housekeeping services.
Continued LIC9099C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Elias Magdaleno
LICENSING EVALUATOR SIGNATURE:

DATE: 07/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 21-AS-20250630103354
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: LODGE AT GLEN COVE, THE
FACILITY NUMBER: 486803921
VISIT DATE: 07/02/2025
NARRATIVE
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During visit LPA observed that multiple staff were actively attempting to clean R1 room, but due to past threats and aggression were waiting for R1 to leave room. Interviews and record review also indicate that R1 is currently under a lawful 30-day eviction notice due to a refusal to clean room or allow staff to clean room. Based upon observations, record review, and interviews, we have found that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore, the allegations/complaint is UNSUBSTANTIATED.


No deficiencies cited.

Exit interview conducted. Copy of report discussed and provided to the Administrator. The signature on the form confirms receipt of documents.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Elias Magdaleno
LICENSING EVALUATOR SIGNATURE:

DATE: 07/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2025
LIC9099 (FAS) - (06/04)
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