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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803921
Report Date: 08/09/2022
Date Signed: 08/10/2022 09:59:30 AM


Document Has Been Signed on 08/10/2022 09:59 AM - 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: 98DATE:
08/09/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
04:05 PM
MET WITH:Grace SandovalTIME COMPLETED:
04:35 PM
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Licensing Program Analyst (LPA) A. Canela conducted an unannounced Case Management- Incident inspection and met with Administrator, Grace Sandoval. On the visit of July 14, 2022 LPA A Canela also met and spoke with Care coordinator, Beatrice Cortez regarding resident (R2). The purpose of this case management visit is to follow up on self reported incident report submitted to Community Care Licensing (CCL).

It was reported resident R2, in memory care made a comment to facility staff that a male staff was inappropriate with R2 during the night shift. Facility attempted to get more information from R2, who later mentioned nothing regarding the matter. Facility notified R2s family and CCL. There was no other complaints from other residents or R2 regarding this matter. Facility has 1 Medication Technician and 2 care staff during the night shifts for the residents in the memory care area.

No additional information was received and no citations issued during this visit.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:
DATE: 08/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/09/2022
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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