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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803921
Report Date: 04/24/2024
Date Signed: 04/25/2024 10:13:41 AM


Document Has Been Signed on 04/25/2024 10:13 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) 653-4728
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY:155CENSUS: 127DATE:
04/24/2024
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
11:33 AM
MET WITH:Jasmine SeiffertTIME COMPLETED:
11:55 AM
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An informal meeting was conducted today in the Santa Rosa Regional Office via Microsoft Teams . Present in the meeting were Licensing Program Manager (LPM) Kimberley Mota, Licensing Program Analyst (LPA), Araceli Canela and Administrator of the Lodge at Glen Cove, Jasmine Seiffert.

The purpose of the Informal meeting was to address concerns regarding a self reported incident by the facility on 2/9/2024 that involved staff S2, S3, S4 and resident R1. Administrator took action, and submitted the required reports, conducted internal investigation and Mandated Reporter retraining for all staff.
Administrator agreed to submit proof of training to Community Care Licensing.





No deficiencies cited during today’s informal meeting.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:
DATE: 04/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/24/2024
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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