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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486801249
Report Date: 05/05/2023
Date Signed: 05/05/2023 07:42:17 PM

Document Has Been Signed on 05/05/2023 07:42 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
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:
05/05/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:39 PM
MET WITH:Mary Jane MendozaTIME COMPLETED:
04:40 PM
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Licensing Program Analyst (LPA) Araceli Canela arrived unannounced to conduct a Required - 1 Year inspection and met with, Administrator, Mary Jane Mendoza. There are currently 5 residents living in this facility. This facility is licensed for 6 non-ambulatory residents, with hospice waiver approved for 2 of the residents and none of the residents are approved for bedridden.

LPA toured facility and grounds and observed facility was found to be clean at a comfortable temperature with all exits free from obstruction. Resident rooms have the required furnishings and linens. Medications are stored locked in a
locked cabinet in the living room area along with resident files. LPA reviewed medications and consulted regarding additional documentation needed if the facility is not going to use the Medication Administration Record (MAR). LPA will return to review changes made and to provide additional guidance per regulations. Facility has at least two days of perishable and one week of non-perishable foods. Fire Extinguisher was found to be charged, and serviced 5/30/2022. Smoke alarms and Carbon monoxide detector are operational. Facility last fire drill was conducted on January 2023. Facility has awake staff during the night as there are no rooms available for staff to sleep in.

Water temperature in bathrooms measured at 107 degrees F which is within the range of 105 to 120 degrees F allowed per regulation. Extra hygiene products and linens were available.

LPA reviewed all resident files, and some staff files and staff files had the required training and proof of CPR/1st Aid expiring 9/2/2023.
Resident files were reviewed and some appraisals were signed but not dated. Facility was advised to get the required signatures and/or redo reports.
Continue report see LIC809-C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE: DATE: 05/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/05/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: MENDOZA CARE HOME IV
FACILITY NUMBER: 486801249
VISIT DATE: 05/05/2023
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Outside yard was observed with no hazards, LPA requested facility to service both side yard gates as the weather has affected them.

Administrator and LPA discussed their Emergency Disaster Plan and Infection Control Plan.

Licensee/Administrator to submit the current following documents by 6/5/2023:


· LIC 308 Designation of Facility Responsibility
· LIC 500 Personnel Report
· LIC 610E Emergency Disaster Plan
· LIC 9020 Register of Facility Residents
Infection Control Plan of Operation (If changes)
Liability Insurance
Copy of current Lease Agreement

No citations issued during todays visit.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE:

DATE: 05/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2023
LIC809 (FAS) - (06/04)
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