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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803996
Report Date: 06/23/2022
Date Signed: 06/23/2022 10:32:17 PM


Document Has Been Signed on 06/23/2022 10:32 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:AGING IN THE BAY 2FACILITY NUMBER:
486803996
ADMINISTRATOR:MENDAROS, CHARMAINEFACILITY TYPE:
740
ADDRESS:1325 POTRERO CIRCLETELEPHONE:
(510) 388-7352
CITY:SUISUN CITYSTATE: CAZIP CODE:
94585
CAPACITY:6CENSUS: 4DATE:
06/23/2022
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
01:52 PM
MET WITH:Charmaine MendarosTIME COMPLETED:
04:28 PM
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Licensing Program Analysts (LPA) Katrina Walters conducted an unannounced post-licensing inspection on 06/23/2022. LPA met with Administrator, Charmaine Mendaros.
During today’s visit LPA observed the following items:
· COVID-19 postings and screening station at entrance. LPA was screened prior to entering.
· Lockable separate cabinets for toxin and knives.
· Food supplies were within regulation
· All exits were unobstructed
·4 smoke detectors and 1 carbon monoxide detector, which were tested and observed to be operational. Auditory devices were turned on during inspection.
· Fire Extinguisher charged and last serviced on 06/14/2021
· Emergency plan/numbers, CCLD complaint poster, Emergency Disaster Plan, Client personal rights and visitor policy.
· Bathrooms were supplied with hand washing supplies, paper products and signs to demonstrate proper hand washing techniques. Grab bars and non-slip mats were in the bathroom for resident safety.
· Water temperature was tested and within regulation of 105 to 120 degrees F
· Supply of linens, incontinence products, hygiene supplies and personal protective equipment were available.
· Administrator Certification (expires 12/12/2022); Required postings (Personal Rights,
· First Aid kit, night-lights, and flashlights for emergency lighting
· Resident's medication was centrally stored and locked.
· Facility records were reviewed for residents and staff. Staff have CPR and 1st Aid certifications. Training on infection control and dementia. Vaccination cards were stored in staff files.

No deficiencies cited during today's inspection
Exit interview conducted with Administrator, Charmaine Mendaros, whose signature below confirms receipt.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Katrina WaltersTELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:
DATE: 06/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/23/2022
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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