<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803921
Report Date: 07/23/2024
Date Signed: 07/23/2024 07:56:37 PM


Document Has Been Signed on 07/23/2024 07:56 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: 132DATE:
07/23/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
04:12 PM
MET WITH:Jasmine Seiffert, Executive DirectorTIME COMPLETED:
05:28 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Araceli Canela arrived unannounced to go over a recent incident that was reported by the facility and met, Jasmine Seiffert, Executive Director (ED).
On July 5, 2024, LPA received an incident report from ED regarding staff (S1) who was inappropriate with their actions towards a Memory Care resident (R1)
LPA spoke with R1, and took statements from staff who were working on the day of the incident and Memory Care Coordinator (S2) Although S2 stated they have done in service training with memory care staff, LPA requested facility to redo training and go more in depth. During LPAs interviews with S2 and other staff, it was clear they may need assistance with understanding residents personal rights and the responsibility of staff being mandated reporters and how to complete an SOC341 to report possible adult abuse.
LPA received records that were requested, the ED did submit the required SOC341 regarding this incident along with a video of the incident. Staff S1 was terminated by the facility and did not return to work after the incident.

LPA also went over several residents (5) who are occupying rooms in the Assisted living area and have a diagnoses of Dementia. LPA requested current medical assessment, service plans and plan on how facility will ensure the safety and supervision of residents with Dementia diagnoses living in assisted living. Plan and records to be sent to LPA by 8/5/2024.
LPA went over Dementia regulations 87705 Care of Persons with Dementia and reminded facility the following: Outdoor facility space used for resident recreation and leisure shall be completely enclosed by a fence with self-closing latches and gates, or walls, to protect the safety of residents. The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident. There is an adequate number of direct care staff to support each resident’s physical, social, emotional, safety and health care needs as identified in his/her current appraisal

LPA will review information, 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: 07/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/23/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1