Facility Evaluation Report

8/14/2025 Licensing Program Analyst (LPA) Shannan Hansen arrived unannounced to conduct a Required - 1 Year inspection of this Residential Care Facility for the Elderly and met with Administrator, Josephine Mendoza. This single story, 5 bedroom, 2 bathroom building has been approved for 6 Non Ambulatory residents by Vallejo Fire Department and has hospice waiver for 2. There are currently 6 residents in care, 3 Dementia diagnosis, 1 Hospice. There were 2 staff at the time of inspection.

At approximately 12:15pm LPA and Administrator toured facility and grounds and observed all required signs posted in common areas. Facility was found to be at a comfortable temperature with all exits free from obstruction. Facility has at least two days supply of perishable and one week of non-perishable foods and items are stored properly. Toxins are stored locked under the sink in kitchen cabinet. Sharps and other dangerous items were inaccessible to residents in care ; although LPA & Administrator observed cleaning supplies and toxins (bleach) on floor of garage with doors unlocked to garage and no audio alarms activated (see pics & LIC809-D) administrator removed items immediately. Hot water temperature measured between 115.7 degrees F and 119.1 degrees F within Title 22 acceptable regulation of 105 to 120 degrees F in 2 of 2 resident’s bathrooms while touring facility. There was a supply of cleaners, hygiene products and paper products available for residents. Bathrooms were equipped with necessary grab bars, and slip-resistant mats, strips, or flooring in all bathtub and shower floors as required by Title 22 regulations. All bedrooms have lighting & appropriate furnishings per Title 22 regulations.

A review of six resident & five staff records as well as two resident medications was conducted. LPA reviewed resident files at 12:45 PM on 8/14/2025 and learned that 6 of 6 residents have an updated reappraisal/needs & care plan, TB and physician’s assessments on file as required by Title 22 Regulation.