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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486890073
Report Date: 10/29/2021
Date Signed: 11/10/2021 03:35:31 PM

Document Has Been Signed on 11/10/2021 03:35 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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:SHIR-LEE'S CARE HOMEFACILITY NUMBER:
486890073
ADMINISTRATOR:LOFTON, ANGELAFACILITY TYPE:
735
ADDRESS:2548 TENNESSEE STREETTELEPHONE:
(707) 648-2964
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY: 4CENSUS: 1DATE:
10/29/2021
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
09:21 AM
MET WITH:Angela LoftonTIME COMPLETED:
11:52 AM
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Licensing Program Analyst (LPA) A. Canela conducted an unannounced Post licensing inspection, met with care Licensee/Administrator, Angela Lofton.
LPA discussed Emergency Disaster Drills to be conducted every 3 months.
During today’s visit LPA observed the following items:
· COVID-19 postings and screening station at entrance. LPA's were screened prior to entering.
· Lockable separate cabinets for toxin and knives.
· All exits were unobstructed
· 8 combination smoke and carbon monoxide detectors, e tested and observed to be operational
· First Aid kit, night-lights, and flashlights for emergency lighting
· Supply of linens, paper products, and hygiene supplies available
· Fire Extinguisher charged (7/22/2021)
· Required furnishings in all bedrooms
· A shed in the backyard used for storage- locked
· Administrator Certification (expires 07/22/2023); Required postings (Personal Rights, Emergency plan/numbers, CCLD complaint poster, Emergency Disaster Plan, and Client personal rights.
· Water temperature was tested and within regulation of 105 to 120 degrees
· Resident's medication was centrally stored and locked.
· Food supplies were within regulation
· Facility records were reviewed for residents and staff. Staff have CPR and 1st Aid. (8/8/23)
Facility records were reviewed for residents and staff. Staff have CPR and 1st Aid
No deficiencies cited during today's inspection
Exit interview conducted with Administrator/Licensee, Angela Lofton
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE: DATE: 10/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/29/2021
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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