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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803921
Report Date: 01/20/2022
Date Signed: 01/21/2022 11:24:59 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:LODGE AT GLEN COVE, THEFACILITY NUMBER:
486803921
ADMINISTRATOR:KINDRED, NICHOLEFACILITY TYPE:
740
ADDRESS:140 GLEN COVE MARINA ROADTELEPHONE:
(707) 592-1157
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY:155CENSUS: 90DATE:
01/20/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:53 PM
MET WITH:Grace Sandoval, AdministratorTIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Araceli Canela arrived unannounced to conduct a Required - 1 Year inspection and met with Administrator, Grace Sandoval. The annual inspection is focused on the Infection Control procedures and practices of this Residential Care Facility for the Elderly.

LPA toured facility and grounds with Administrator and observed some COVID-19 precaution signs posted in common areas to promote hand washing and physical distancing. LPA was screened for COVID-19 symptoms upon entrance to this facility. Visitors are screened for COVID-19 symptoms (including temperature check) upon arrival to the facility. Infection control practices are present: entry procedures, face coverings, daily monitoring and temperatures checked for residents and staff, and 30-day PPE supply. Staff follow indoor visitation requirement for none essential visitors and verify visitors are vaccinated, have had all recommended doses and provide evidence of a negative SARS-CoV-2 test within one day of visitation for antigen tests, and within two days of visitation for PCR tests. Staff clean and disinfect the facility daily. Administrator stated high touched surface areas are disinfected daily. Bathrooms are equipped with liquid soap, paper towels and garbage cans. Facility submitted a Covid-19 mitigation plan, and plan was reviewed 8/20/2021. Caregivers have completed PPE training and some have been N-95 Fit tested.
This facility is licensed to serve up to 155 residents. There are 3 floors being used, the first floor serves memory care residents and doors have 30 second delayed egress approved by the fire department. No fire safety hazards observed. Fire Extinguisher were found to be charged & serviced 12/272021. Floors have stair evacuation chairs. Facility has hard wire Smoke alarms, fire sprinklers that are serviced yearly and Carbon monoxide detectors.
LPA requested a Copy of Change of Administrator paperwork and an update on all staff N95 fit testing completion dates by 1/31/22.
Exit interview conducted with Administrator. Due to printer malfunction, this report will be emailed to Administrator.
No deficiencies cited during this inspection
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:

DATE: 01/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2022
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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