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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803921
Report Date: 01/29/2025
Date Signed: 01/29/2025 04:52:14 PM

Document Has Been Signed on 01/29/2025 04:52 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:LODGE AT GLEN COVE, THEFACILITY NUMBER:
486803921
ADMINISTRATOR/
DIRECTOR:		JASMINE SEIFFERTFACILITY TYPE:
740
ADDRESS:140 GLEN COVE MARINA ROADTELEPHONE:
(707) 653-4728
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY: 155CENSUS: 140DATE:
01/29/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Jasmine Seiffert, Executive Director/AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:40 PM
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Licensing Program Analyst (LPA) A. Canela, arrived unannounced to conduct this required 1 year inspection and met with Jasmine Seiffert, Executive Director/Administrator. LPA toured the facility with Assisted Living care coordinator, Beatriz Cortez.

This facility is located near the Glen Cove Marina and has a total of 141 apartments. There are two floors in the facility and a ground floor. The ground floor has a section that is used for memory care residents and has a locked perimeter that was approved by the fire department with 30 second delayed egress that was tested today and operational.

Facility was at a comfortable temperature with all exits free from obstruction. Some resident’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was found to be last charged on 12/10/2024. The kitchen area was found clean with sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Residents are provided various alternative food options per meal with the facility ensuring well balanced and nutritious foods. All resident bedrooms have appropriate lighting and furniture with a supply of extra blankets and linens.

There was a supply of hygiene products, paper products, PPE and emergency food and water. LPA conducted a sample review of resident files. Staff have current 1st Aid training and med techs have proof of CPR on file. Toxins are stored in locked maintenance closets and carts located throughout the facility.


Continued onto LIC809-C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE: DATE: 01/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/29/2025
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: LODGE AT GLEN COVE, THE
FACILITY NUMBER: 486803921
VISIT DATE: 01/29/2025
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LPA requested the following documents be sent to CCL by COB 2/23/2025:

LIC 308 Designated Facility Responsibility
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
LIC 9020 Register of Facility client’s/client’s
Copy of Administrator Certificate(s)
Copy of Liability Insurance


No deficiencies cited during todays inspection
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE:

DATE: 01/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2025
LIC809 (FAS) - (06/04)
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