486803921-6-22-2022-21-AS-KMOA-CFNLSF-20220623090038

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 486803921
Report Date: 06/21/2022
Date Signed: 06/22/2022 10:14:59 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/10/2022 and conducted by Evaluator Araceli Canela

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20220110151638

FACILITY NAME:	LODGE AT GLEN COVE, THE		FACILITY NUMBER:	486803921
ADMINISTRATOR:	KINDRED, NICHOLE		FACILITY TYPE:	740
ADDRESS:	140 GLEN COVE MARINA ROAD		TELEPHONE:	(707) 592-1157
CITY:	VALLEJO	STATE: CA	ZIP CODE:	94591
CAPACITY:	155	CENSUS: 93	DATE:	06/21/2022
		UNANNOUNCED	TIME BEGAN:	03:35 PM
MET WITH:	Grace Sandoval, Administrator		TIME COMPLETED:	05:06 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Medication accessible to residents in care
Staff are not adequately trained

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA), A. Canela arrived unannounced, for the purpose of gathering additional information and delivering findings regarding the above allegations.

LPA toured the inside of this facility, made observations, requested additional records, and on previous visits gathered statements.
It was alleged medication is accessible to residents in care in that facility has left the medication room and or medication cabinet unlocked or have left the medication on the table for residents to take. LPA conducted several inspections and did not find the medication room or cabinet unlocked.

Continue report see LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli Canela	TELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:	DATE: 06/21/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 2

Control Number 21-AS-20220110151638

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
	VISIT DATE: 06/21/2022

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
26
27
28
29
30
31
32

LPA did not observe any medication left unattended in the dining room table, dining room floor or resident rooms toured. There were also no corroborating statements made of medication being left accessible to residents.

It was also alleged staff are not adequately trained and it was also reported the medication tech hands out medication to other staff to deliver to the residents. LPA was unable to get any statements from residents. Staff interviewed denied they provided other staff who are not trained with residents medication to pass out. Staff training records reviewed, were found current. There were also no corroborating statements made by staff interviewed.

Although the allegations may be true, or are valid, there is not a preponderance of evidence to prove the alleged violations did, or did not, occur. Therefore, the allegations for Medication accessible to residents in care and Staff are not adequately trained are both UNSUBSTANTIATED.

No citations issued.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli Canela	TELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:	DATE: 06/21/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 2