216803761-9-21-2023-21-AS-CFES-CVVUAQ-20230921152508

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 216803761
Report Date: 09/21/2023
Date Signed: 09/21/2023 03:25:32 PM

Document Has Been Signed on 09/21/2023 03:25 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:	GREENWOOD ASSISTED LIVING		FACILITY NUMBER:	216803761
ADMINISTRATOR:	JOLLY CARUNGCONG		FACILITY TYPE:	740
ADDRESS:	233 WEST END AVE		TELEPHONE:	(415) 258-1560
CITY:	SAN RAFAEL	STATE: CA	ZIP CODE:	94901
CAPACITY:	47	CENSUS: 21	DATE:	09/21/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:40 AM
MET WITH:	Staff Member, Ian Cabigting, and Administrator, Jolly Carungcong		TIME COMPLETED:	03:35 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	At approximately 9:40AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Required 1 Year visit and met with Staff Member, Ian Cabigting. Administrator, Jolly Carungcong, arrived during visit at approximately 10:00AM. Facility serves residents with dementia and has a plan of operation for dementia care and programming on file. Facility has an approved fire clearance for 41 non-ambulatory and 6 bedridden residents for a total capacity of 47 residents. Facility has an approved hospice waiver for 6 individuals. Upon arrival, LPA was informed that there were 21 Residents in care and 7 staff on-site. At approximately 10:05AM, LPA reviewed the Facility's Staff Roster and found that all staff on-site were background cleared and associated to the facility per regulation. At approximately 10:25AM, LPA conducted a walk-though of the facility with Administrator. LPA observed the following: The facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Facility had emergency lighting. Facility is a 1 story building with 26 bedrooms, 2 shower rooms, and common spaces. Facility has an Infection Control plan on file. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Toxins and dangerous items were observed to be stored inaccessible to clients. There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for Residents. Mattress pads were in place or available for Resident use. LPA tested a sample size of 10 sinks for hot water temperatures. LPA found that all sinks tested were within Title 22 regulations of 105 to 120 degrees Fahrenheit. At approximately 11:25AM, LPA reviewed a sample size of 7 staff files, 6 resident files and 6 resident medication records. Staff and resident files were found to be well organized and thorough. During Staff Review, LPA observed that 2 of 7 staff members were missing their Health Screening Report (See Technical Violation, LIC9102, Regulation 87411(f)). Staff have current first Aid/CPR certifications. Resident Medications were found to be centrally stored and secure. During Medication Review, LPA was informed that the facility pre-pours medication 16 hours in advance. LPA notified facility that pre-pouring medications is against regulation (See Technical Violation, LIC9102, Regulation 87465(h)(5)). Continued on LIC809C

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 09/21/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023

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: GREENWOOD ASSISTED LIVING	FACILITY NUMBER: 216803761
	VISIT DATE: 09/21/2023

NARRATIVE

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Continued from LIC809

Facility's fire extinguishers were last inspected November 2022. Facility's last fire drill was conducted August 2023. Facility had their sprinkler system inspected and replaced September 2023.

LPA also followed up on a self-reported incident that were submitted to Community Care Licensing (CCL).

Death Report 1: CCL received death report on 08/17/2023. The report states that on 08/13/2023, Resident 1 (R1) was observed to be doing well prior to lunchtime. When facility staff went to remind R1 for lunch, R1 was observed to be on the floor and was unresponsive. Facility contacted Emergency Personnel where R1 was pronounced to have passed away. R1 was not on hospice. Facility made all appropriate notifications per regulation.

Per conversation with Administrator, on 08/13/2023, R1 was observed to be doing well at approximately 11:30AM, sitting in the dining room for lunch. R1 was then observed to walk back to their room to wait for lunch to be ready and was checked on at approximately 12:20PM where R1 was found to be unresponsive. LPA requested for the Death Certificate to be submitted to CCL for review.

LPA unable to complete the Annual Inspection. Annual Continuation Visit to be conducted at a later date.

No Deficiencies cited during visit.

Exit interview conducted. Copy of report, LIC9102 (Technical Advisory/Violation), and LIC811 (Confidential Names) discussed and provided to Administrator. Signature on form confirms receipt of documents.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 09/21/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023

LIC809 (FAS) - (06/04)

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