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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486801249
Report Date: 06/17/2021
Date Signed: 06/21/2021 12:42:33 PM

Document Has Been Signed on 06/21/2021 12:42 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:MENDOZA CARE HOME IVFACILITY NUMBER:
486801249
ADMINISTRATOR:MENDOZA, MARY JANEFACILITY TYPE:
740
ADDRESS:808 FOOTHILL DR.TELEPHONE:
(707) 642-4221
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY: 6CENSUS: 5DATE:
06/17/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Mary Jane MendozaTIME COMPLETED:
04:45 PM
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Licensing Program Analyst (LPA) A. Canela conducted an unannounced Annual Required – 1 yr. Infection Control inspection to this facility and was greeted by Administrator Mary Jane Mendoza. LPA conducted a Risk Assessment with Administrator. There were 2 staff providing care and supervision for 5 residents. LPA observed that all staff were wearing face mask.

LPAs temperature was checked upon entry and logged into a binder. Hand sanitizer and disposable mask were available. LPA and Administrator conducted a tour of the facility and observed that the facility was a comfortable temperature and passageways/exits were free from obstructions. Resident rooms were furnished per regulation.

Signs were posted throughout the facility to promote hand washing and social distancing. Residents temperatures are being monitored daily and results are documented in binder. Facility has a 60+ day supply of PPE. Facility has a 30-day supply of medication for residents. Facility has conducted staff training on infection control along with LPH.

LPA provided the following guidance to staff:

Add a field on sign-in sheet so visitors can include their contact information.

  • Complete N-95 Fit Testing for all staff.
  • Review PINs 21-18-ASC and 21-17.1-ASC for new guidance regarding visitation, communal dining, etc.

No deficiencies were cited during today's inspection.

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE: DATE: 06/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/17/2021
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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