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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804180
Report Date: 09/24/2024
Date Signed: 09/24/2024 05:27:25 PM


Document Has Been Signed on 09/24/2024 05:27 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: 5DATE:
09/24/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Mary Ann Ordono, CaregiverTIME COMPLETED:
05:40 PM
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At approximately 12:45 PM, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to conduct a required 1-year annual inspection and was greeted by Mary Ann Ordono, Caregiver/Responsible Party (PR). Licensee was contacted via telephone and gave LPA permission to continue with the inspection with the RP. Facility is a Residential Care Facility for the Elderly (RCFE) with five (5) residents in care. All residents were present during today's inspection. Facility has a hospice waiver for four (4), a bedridden waiver for one (1), is approved for all non-ambulatory residents, and currently has one (1) hospice residents in care.

At approximately 1:00 PM, LPA initiated a tour of the facility with RP and observed the following: Facility is a one story home, was a comfortable temperature, and passageways were free from obstructions. Water temperatures in residents' bathrooms measured within the allowable range of 105 to 120 degrees F per Title 22 regulations. LPA observed a supply of clean linens and paper products available to residents. Residents' bedrooms were inspected and observed to have the appropriate furnishings as outlined in Title 22 regulations. Cabinets containing cleaning supplies and other items that could pose a risk were locked. Facility has at least two days of perishable food and one week of non-perishable foods, as well as an emergency water supply. Medications were centrally stored and locked. There is a covered seating area in the enclosed front yard with outdoor space for activities. LPA observed a locked shed in the backyard which LPA inspected and observed the contents which consist of tools, chemicals, and extra facility equipment. LPA observed an activity schedule and was informed that the facility conducts morning exercises at least 4 times per week. LPA observed games, puzzles, and activities for residents in care. RP agreed to purchase an internet access device and facility has internet service available to residents in care. The facility telephone was tested an operational during inspection.

Facility's fire extinguisher was observed charged and was last serviced February 2024. Smoke and Carbon Monoxide detectors were tested and operational during inspection.

Continued on LIC809-C...
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Julie FlorioTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 09/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/24/2024
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 4


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 4
FACILITY NUMBER: 486804180
VISIT DATE: 09/24/2024
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Continued from LIC809C...

Facility conducts quarterly disaster drills, and the most recent drill was conducted August 2024. LPA observed the facility's infection control plan, first aid kit, PPE, and other emergency supplies. LPA reviewed facility's emergency disaster plan last updated September 2023.

At approximately 2:30 PM, Licensee, Charmaine Menderos arrived. LPA reviewed five (5) staff files which all contained the required paperwork including the required CPR and First Aid training certificates and documentation of the required initial, annual, and medication training hours. LPA conducted file review of all five (5) resident files and observed all five (5) files contained all the required documents per Title 22 regulations. LPA advised Licensee to ensure all documents are signed and dated.

At approximately 4:00 PM, LPA reviewed medications and medication records which are maintained and stored in compliance with regulation. Licensee states facility and residents' families work together to coordinate medical and dental appointments and residents' family coordinate transportation to and from visits. Facility does not manage cash resources for residents.

LPA observed Resident 1 (R1) in a bedroom not cleared for a bedridden resident. Facility does have a room cleared by the fire department for a bedridden resident. Licensee agreed to switch the residents' rooms to bring the facility into compliance.

No deficiencies were cited during inspection.

Updated copies of the following documents are to be submitted to CCL within 30 days of this visit:
  • LIC610 Emergency Disaster Plan (updated)
  • LIC500 Personnel Report (updated)
  • LIC308 Designation of Responsibility (for staff)
  • Proof of Liability Insurance

Exit interview conducted with RP whose signature on form confirms receipt of documents.

SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Julie FlorioTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 09/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2024
LIC809 (FAS) - (06/04)
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