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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486803921
Report Date: 07/29/2025
Date Signed: 07/29/2025 11:13:01 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
07/22/2025 and conducted by Evaluator Christopher Arnhold
COMPLAINT CONTROL NUMBER: 21-AS-20250722102044
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:
07/29/2025
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Jasmine SeiffertTIME COMPLETED:
11:20 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Neglect/lack of care and supervision
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
At approximately 10:30AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced to open an investigation into the above allegation. LPA met with Executive Director Jasmine Seiffert and reviewed records. Based on records reviewed and interviews conducted, Resident (R1) was issued an eviction notice on 06/19/2025 for refusing care and being aggressive. LPA reviewed R1's care plan and observed facility has been making updates as needed per regulation. Based on records reviewed, R1 has been refusing care and not allowing staff into their room. Facility has taken action to ensure the well-being of R1 by issuing a 30 day eviction. Facility staff have continued to attempt to provide care for R1 when they allow it.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Christopher Arnhold
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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