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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803761
Report Date: 07/22/2021
Date Signed: 07/22/2021 02:56:12 PM

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:GREENWOOD ASSISTED LIVINGFACILITY NUMBER:
216803761
ADMINISTRATOR:LISADIBARTOLO&ANGELAGRENASFACILITY TYPE:
740
ADDRESS:233 WEST END AVETELEPHONE:
(415) 258-1560
CITY:SAN RAFAELSTATE: CAZIP CODE:
94901
CAPACITY:47CENSUS: 17DATE:
07/22/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Licensee, W. Mark BelloTIME COMPLETED:
03:10 PM
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Licensing Program Analyst (LPA), Farhaan Sarangi arrived at Greenwood Assisted Living for the purpose of conducting a Required 1-year inspection. LPA was greeted at the front door by licensee, W. Mark Bello, and was granted access into the facility.

LPA toured the facility with the licensee, W.Mark Bello. Facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Fire Extinguisher was found to be last charged on January 2021. Facility smoke detectors are hard wired and sound directly to the fire station. Smoke detectors and fire sprinklers are inspected annually. There are emergency lights in many of the fixtures in the common areas of the facility that come on should a power outage occur. Hot water temperature measured between acceptable regulation of 105 to 120 degrees. Facility serves residents with dementia and has special care plan of operation and programming. There was a sufficient supply of both perishable and non-perishable foods as required by Title 22 Regulations. LPA toured the kitchen area. Food is available for residents any time of the day. There is a daily activity schedule for residents. Toxins are stored in a locked laundry room. There was a supply of cleaners, hygiene products and paper products available for residents. Facility double bedrooms occupancy have bathrooms for residents. LPA requested the following documents: LIC 309, LIC 308, updated liability insurance and LIC 500.

LPA advised facility to contact County Public Health and Community Care Licensing immediately if symptoms or COVID-19 + in the facility. Facility has PPE supply stored in the storage office located in the staff room. Staff have had all PPE training required on file and still working towards acquiring N-95 fit testing.

No deficiencies were observed or cited during today's Required 1- Year inspection. Exit interview was conducted and a copy of this report was emailed to the facility Licensee, W.Mark Bello.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan SarangiTELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2021
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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