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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803921
Report Date: 08/03/2023
Date Signed: 08/03/2023 10:45:06 AM


Document Has Been Signed on 08/03/2023 10:45 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: 106DATE:
08/03/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Carol DowellTIME COMPLETED:
11:00 AM
NARRATIVE
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Licensing Program Analyst Leibert arrived unannounced and met with Administrator. During the course of a complaint investigation, LPA observed that R1's condition significantly changed since R1's initial placement in the facility. R1's Care Plan dated 05/02/2023 states that R1 has no special care needs and is "self managed." Since the initial assessment, R1 has lost substantial mobility and Home Health RN has advised that R1 should rest in bed for several hours following meals in order to relieve pressure on an injury. Since R1's appraisal has not been updated as required by 87463 to reflect this change in condition, a deficiency is cited.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.

Report left.

SUPERVISOR'S NAME: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David LeibertTELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:
DATE: 08/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/03/2023
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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Document Has Been Signed on 08/03/2023 10:45 AM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/03/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/17/2023
Section Cited
CCR
87463(a)

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87463(a) REAPPRAISALS. The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate…*** Based on statements and documents, this requirement has not been met as
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Administration agrees to produce an updated care plan for R1. Administration to provide a copy of the updated plan to CCL by POC date in order to clear the deficiency.
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evidenced by: RI’s condition significantly changed since 5/2/2023 appraisal and now requires substantial bed rest due to pressure injury. No update to R1’s appraisal has been made. This poses a potential risk to R1’s health and safety.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David LeibertTELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:
DATE: 08/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/03/2023
LIC809 (FAS) - (06/04)
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