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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803921
Report Date: 01/13/2024
Date Signed: 01/13/2024 03:27:48 PM


Document Has Been Signed on 01/13/2024 03:27 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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, THEFACILITY NUMBER:
486803921
ADMINISTRATOR:JASMINE SEIFFERTFACILITY TYPE:
740
ADDRESS:140 GLEN COVE MARINA ROADTELEPHONE:
(707) 592-1157
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY:155CENSUS: DATE:
01/13/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:35 PM
MET WITH:Beatriz CortezTIME COMPLETED:
03:37 PM
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LPA Hiratsuka, conducted this unannounced annual visit. LPA toured with Assisted Living Care Coordinator Beatriz Cortez.

This facility has three floors. This building has assisted living and a memory care unit that has a delayed egress. There is a mix of one bedroom, two bedroom, and studio apartments. The memory care unit apartments are studios. Some of the memory care apartments share a shower. The showers in the shared units are locked and cannot be accessed without a caregiver. There are several common areas throughout the building. There is an interior courtyard.

LPA toured several apartments.

Several staff and resident records were reviewed.

The following shall be updated and submitted to CCLD by 02/10/2024:
-LIC 500 facility personnel or staff schedule
-LIC 308 designation of administrative responsibility
-copy of current administrator certificate
-liability insurance

Multiple topics were discussed

No deficiencies cited.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Kerry HiratsukaTELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:
DATE: 01/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/13/2024
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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