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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803921
Report Date: 02/02/2024
Date Signed: 02/05/2024 09:05:19 AM


Document Has Been Signed on 02/05/2024 09:05 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:JASMINE SEIFFERTFACILITY TYPE:
740
ADDRESS:140 GLEN COVE MARINA ROADTELEPHONE:
(707) 592-1157
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY:155CENSUS: 125DATE:
02/02/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
04:15 PM
MET WITH:Jasmine Seiffert, Executive Director/AdministratorTIME COMPLETED:
04:51 PM
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Licensing Program Analyst (LPA) Araceli Canela arrived unannounced and met with Jasmine Seiffert, Executive Director /Administrator. During a complaint investigation LPA discovered staff S1 who was not associated to this facility as required. In addition LPA found resident R1 and R2 who have a Dementia Diagnoses to have items such as a cup filled with some type of vitamins, a sharp knife and a hammer.

Due to time restraints, LPA will return to issue citations warranted and LPA along with staff S2 removed the items from the residents rooms and placed them inaccessible. LPA went over such items with Administrator.


No citations issued at this time.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:
DATE: 02/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/02/2024
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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