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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803761
Report Date: 03/27/2024
Date Signed: 03/27/2024 05:43:29 PM


Document Has Been Signed on 03/27/2024 05:43 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:GREENWOOD ASSISTED LIVINGFACILITY NUMBER:
216803761
ADMINISTRATOR:JOLLY CARUNGCONGFACILITY TYPE:
740
ADDRESS:233 WEST END AVETELEPHONE:
(415) 258-1560
CITY:SAN RAFAELSTATE: CAZIP CODE:
94901
CAPACITY:47CENSUS: DATE:
03/27/2024
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Licensee, Mark Bello, and Administrator, Jolly CarungcongTIME COMPLETED:
05:45 PM
NARRATIVE
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An Office meeting was conducted today in the Santa Rosa Regional Office. The following individuals were present in the meeting: Regional Manager, Carla Nuti-Martinez, Licensing Program Manager, Victoria Bertozzi, Licensing Program Analyst, Caitlynn Felias, Licensee, Mark Bello, and Administrator, Jolly Carungcong. The purpose of the office meeting was to hold an Informal meeting to address areas of concern identified by the Department.

The following areas were discussed during the meeting today:

  • We amended Complaint 21-AS-20230417124321 which also has a 2nd level appeal under review.
  • We delivered findings for Complaint 21-AS-20231017092122, issued citations, and noticed the facility that additional civil penalty may be assessed based on Health and Safety Code 1569.49(e) or (f), or 1548(e) or (f), 1568.0822(e) or (f).
  • We cited the facility for Administrator Qualifications and Duties related to concerns around:
    • Incidental, Medical, and Dental Care
    • Staff Training
    • Facility 911 policies and procedures
    • Facility documentation policies and procedures
    • Resident Care Plans
    • Visitation
    • Eviction Procedures
Copies of Regulation 87464 Basic Services, 87411 Personnel Requirements – General, 87468.2 Additional Personal Rights of Residents in Privately Operated Facilities, 87633 Hospice Care of Terminally Ill Residents, and 87224 Eviction Procedures were provided.

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Continued on LIC809C

SUPERVISOR'S NAME: Victoria BertozziTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Caitlynn FeliasTELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:
DATE: 03/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/27/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


Document Has Been Signed on 03/27/2024 05:43 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405


FACILITY NAME: GREENWOOD ASSISTED LIVING
FACILITY NUMBER: 216803761

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/27/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
03/28/2024
Section Cited
CCR
87405(h)(5)

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87405 Administrator - Qualifications and Duties: (h)Administrator shall have the responsibility to: (5) Provide or ensure the provision of services to...residents with appropriate regard for... physical & mental well-being and needs... Requirement wasn't met as evidenced by: based on interviews,
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Licensee to have Administrator review Regulation 87405 - Administrator Qualifications and Duties and submit a written policy defining Administrator Role and Responsibilities. Plan to be submitted by POC due date of 03/28/2024.
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records reviewed, & observations, Administrator didn't ensure R1 received required services outlined in appraisal, by directing staff or updating care plan, when it was evident assistance w/ incontinence care was insufficient & they were notified. This poses an immediate health and safety risk.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Victoria BertozziTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Caitlynn FeliasTELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:
DATE: 03/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/27/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: GREENWOOD ASSISTED LIVING
FACILITY NUMBER: 216803761
VISIT DATE: 03/27/2024
NARRATIVE
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Continued from LIC809

The Department discussed the Technical Support Program (TSP) should the facility be open to having TSP work with them on concerns listed above.

Exit interview conducted. Plan of Corrections reviewed and developed with Licensee and Administrator. Copy of report, LIC809-D, and Appeal Rights discussed and provided to Licensee and Administrator. Signature on form confirms receipt of documents.

SUPERVISOR'S NAME: Victoria BertozziTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Caitlynn FeliasTELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:

DATE: 03/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3