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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804180
Report Date: 10/26/2023
Date Signed: 10/26/2023 04:15:04 PM


Document Has Been Signed on 10/26/2023 04:15 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:AGING IN THE BAY 4FACILITY NUMBER:
486804180
ADMINISTRATOR:MENDAROS, CHARMAINEFACILITY TYPE:
740
ADDRESS:2290 CORMORANT DRIVETELEPHONE:
(510) 388-7352
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY:6CENSUS: 0DATE:
10/26/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Charmine Mendaros, AdministratorTIME COMPLETED:
04:45 PM
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Licensing Program Analyst(LPA) Carol Fowler arrived to conduct a Pre-Licensing Inspection and was greeted by Applicant and Co-Applicant Charmine Mendaros, Administrator and Michael Mendaros are the current licensee/Administrator of Aging In The Bay I, 2, and 3 Adult facility(RCFE). Component III orientation was completed with Administrator, Charmine Mendaros.

LPA and Administrator, conducted a walk through of the facility that will have 6 clients admitted once licensed. LPA observed the following: There was a supply of perishable and nonperishable food. There was a supply of water. Facility had a first aid kit, including the first aid guide book. Each private client room was furnished with all required items per regulation. Additional linens were available for use as needed. Bathroom had grab bars and non-slip flooring/mat for safety as needed. Hot water will be monitored to ensure it is not lower than 105.F and no higher than 120.F, per regulation. Facility has a backyard that includes a deck in the frontyard for clients use. There is a ramp from the kitchen area slider that leads into the family room and the backyard, which is also the fire exit from the back of the home. Facility has enough dishes and cook ware to accommodate each client. Medications will be stored in a locked medication closet. Toxins/cleaners will be stored in locked cabinets located in the family room.
Facility has received a fire clearance approval from the local fire department dated 08/31/2023. Fire extinguisher, one (1), was purchased and tagged, as required, expires 9/15/2024. All smoke alarms, ten (10), and 2 carbon monoxide detector, were all working properly during the inspection. Facility has a required infection control plan. Facility has an emergency disaster plan as required.

Administrator will need to purchase a mattress for bedroom #1, and turn down water heater to meet 105.F and no higher than 120.F, per regulation.

LPA will forward a copy of the prelicensing report to the application Analyst; The application Analyst will notify the applicants of the status of their application.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: 707-588-5053
LICENSING EVALUATOR SIGNATURE:
DATE: 10/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/26/2023
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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