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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803921
Report Date: 07/29/2022
Date Signed: 07/29/2022 04:34:08 PM


Document Has Been Signed on 07/29/2022 04:34 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:KINDRED, NICHOLEFACILITY TYPE:
740
ADDRESS:140 GLEN COVE MARINA ROADTELEPHONE:
(707) 592-1157
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY:155CENSUS: 90DATE:
07/29/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Manuel Ferrer, Maintenance DirectorTIME COMPLETED:
04:45 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) Karina Canela arrived unannounced for the purpose of ensuring the health and safety of residents regarding an incident which was self-reported on 07/28/2022 by phone and incident report. LPA met with Manuel Ferrer, Maintenance Director. Administrator Grace Sandoval was unavailable during time of inspection. LPA was screened for COVID-19 prior to entry as required.

The facility reported staff observed smoke outside of the dinning room window coming from an air conditioning unit located outside of the building. Staff took immediate action with a fire extinguisher to contain the fire. The Fire Department was contacted to confirm the fire was contained. It was reported residents were not affected or hurt by the fire.
Per the incident report submitted by the facility, residents were verbally notified and their responsible parties of the fire incident, which was extinguished. Smoke from the fire entered the ground level of the facility into 1 resident apartment. The HVAC company was contacted and scheduled to replace the damaged air conditioning unit and fire extinguishers used.

During today's visit, LPA observed there was no structural damage to the walls or ceiling of the resident's apartment near where the fire occurred. The facility ventilated the resident's apartment and provided a fan to help with the smell of smoke in resident's (R1 & R2) apartment. Additionally, the facility has given the option to relocate R1 & R2 to another apartment in the meantime for repairs and deep cleaning to be completed. Manuel stated the replacement of the HVAC unit is scheduled for next week.
    All staff wore masks during this visit.
                            No deficiencies cited during today's inspection
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Karina CanelaTELEPHONE: 707-588-5054
LICENSING EVALUATOR SIGNATURE:
DATE: 07/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/29/2022
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