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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803921
Report Date: 05/10/2024
Date Signed: 05/10/2024 05:03:26 PM


Document Has Been Signed on 05/10/2024 05:03 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
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: 130DATE:
05/10/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
04:40 PM
MET WITH:Jasmine Seiffert, Executive Director/Administrator TIME COMPLETED:
05:04 PM
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Licensing Program Analyst (LPA) Canela arrived unannounced and met with Jasmine Seiffert, Executive Director/Administrator.

During the course of a complaint investigation, LPA discovered the facility Assisted Living Care Coordinator failed to report several incidents and a Death report for resident R1 to Community Care Licensing as required. Incident reports and death report not reported were in November 2023 and prior to this facilities new Executive Director.




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.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:
DATE: 05/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2024
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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Document Has Been Signed on 05/10/2024 05:03 PM - 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: 05/10/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/17/2024
Section Cited
CCR
87211(a)(1)(A)

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87211(a)(1)(A)Reporting Requirements (a)Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:
(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident name.............; attending physician's name, findings, and treatment, if any; and disposition of the case. (A) Death of any resident from any cause regardless of where the death occurred, including but not limited to a day program, a hospital, en route to or from a hospital, or visiting away from the facility.
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Facility to submit missing incident reports. Death report was provided during todays visit. Facility to send in written plan on how facility
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This requirement was not met as evidenced by: The facility failed to report several incidents and the Death report in November 2023 for resident R1. This is a potential risk to the health & safety of residents in care
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will ensure care coordinator/facility staff will send in required reports timely. New administrator to provide proof all staff have been trained in reporting requirements. Written Plan of correction due 5/15/24 & staff training due 5/17/2024

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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: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:
DATE: 05/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2024
LIC809 (FAS) - (06/04)
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