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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803761
Report Date: 07/29/2026
Date Signed: 07/29/2026 03:00:05 PM

Document Has Been Signed on 07/29/2026 03:00 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/
DIRECTOR:		FRANK NOLAFACILITY TYPE:
740
ADDRESS:233 WEST END AVETELEPHONE:
(415) 258-1560
CITY:SAN RAFAELSTATE: CAZIP CODE:
94901
CAPACITY: 47CENSUS: 25DATE:
07/29/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:05 AM
MET WITH:Administrator/Executive DIrector, Frank NolaTIME VISIT/
INSPECTION COMPLETED:
03:10 PM
NARRATIVE
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At approximately 9:05AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Required 1 Year visit and met with Executive Director/Administrator, Frank Nola. 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 8 individuals. Upon arrival, LPA was informed that there were 25 Residents in care and 8 staff members on-site. Facility currently has a Probationary License for 2 years per their Stipulation Waiver and Order, Legal Case #7225086303C, effective 07/15/2026 - 07/15/2028.

Facility's Stipulation Waiver and Order, Legal Case # 7225086303C, effective 07/15/2026, was reviewed with Executive Director/Administrator.

At approximately 10:25AM, LPA reviewed the Facility's Staff Roster and found that all staff on-site were background cleared and associated to the facility per regulation. LPA conducted a walk-though of the facility with Executive Director/Administrator, and Staff Member, Jolly Carungcong. The following was observed: 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 23 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 residents. 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. A sample size of 6 facility sinks were tested and were found to be within Title 22 regulations of 105 to 120 degrees Fahrenheit. Facility has a total of five (5) delayed egress doors. All delayed egress doors were tested and operational.

Facility fire extinguishers were last inspected March 2026. Facility's smoke and carbon monoxide detectors are hardwired
Continued on LIC809C
Victoria Bertozzi
Caitlynn Felias
DATE: 07/29/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/29/2026
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 5
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: GREENWOOD ASSISTED LIVING
FACILITY NUMBER: 216803761
VISIT DATE: 07/29/2026
NARRATIVE
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Continued from LIC809

and were last inspected March 2026. Facility's sprinkler and fire system is inspected every 5 years with the last inspection conducted May 2023. Facility's sprinkler system is scheduled to be inspected again May 2028. Facility's last emergency/disaster drill was conducted April 2026. It was observed that facility's April 2026 drill was conducted with only Morning/AM staff members and did not include Evening/PM or Night/NOC staff members. Facility's Emergency Disaster Plan and Infection Control plan were last reviewed and updated July 2026.

During walkthrough it was observed that multiple instances of food located in the facility fridges and food storage areas were expired, improperly stored, or unlabelled/not dated. All observed instances were disposed of during visit. It was also observed that facility did not have an adequate supply of emergency water accessible in the event they needed to shelter in place for 72 hours.

LPA reviewed staff files. Staff files were all found to be well organized and thorough. Staff files had current First Aid/CPR certification, and were found to have completed annual training. Administrator's Certificate for Frank Nola (6072967740) was current with an expiration date of 01/05/2027.

LPA unable to complete Annual Inspection. Annual Continuation Visit to be conducted at a later date to finish file review and medication audit.

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.

Exit interview conducted. Copy of report, Plan of Corrections, Appeal Rights, and Copy of Probationary License discussed and provided to Executive Director/Administrator. Signature on form confirms receipt of documents.

NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Caitlynn Felias
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/29/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2026
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 07/29/2026 03:00 PM - It Cannot Be Edited


Created By: Caitlynn Felias On 07/29/2026 at 02:10 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: GREENWOOD ASSISTED LIVING
FACILITY NUMBER: 216803761

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/29/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(a)
General Food Service Requirements
(a) The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents an shall meet the Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council. All food shall be selected, stored, prepared and served in a safe and healthful manner.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations made, Licensee did not comply with the section cited above. Multiple instances of food and drinks located in the facility fridges and food storage areas were expired, improperly stored, or unlabelled/not dated. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/10/2026
Plan of Correction
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Licensee to submit a written plan how they will ensure that facility food is stored in a safe and healthful manner. Plan to be submitted to Community Care Licensing (CCL) by POC due date of 08/10/2026. Licensee to also submit staff training on food services by POC due date of 08/21/2026.
Type B
Section Cited
HSC
1569.695(a)(2)
Other Provisions
(a)In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: (2) Plans for the facility to be self-reliant for a period of not less than 72 hours immediately following any emergency or disaster, including, but not limited to, a short-term or long-term power failure. If the facility plans to shelter in place and one or more utilities, including water, sewer, gas, or electricity, is not available, the facility shall have a plan and supplies available to provide alternative resources during an outage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations made, Licensee did not comply with the section cited above and did not ensure that there was adequate emergency water supply in the event the facility had to shelter in place for at least 72 hours. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/10/2026
Plan of Correction
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Licensee provided proof of receipt during visit. Licensee to submit photos of delivered water by POC due date of 08/10/2026
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Victoria Bertozzi
NAME OF LICENSING PROGRAM MANAGER:
Caitlynn Felias
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/29/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/29/2026


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 07/29/2026 03:00 PM - It Cannot Be Edited


Created By: Caitlynn Felias On 07/29/2026 at 02:10 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: GREENWOOD ASSISTED LIVING
FACILITY NUMBER: 216803761

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/29/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations made, Licensee did not comply with the section cited above. Licensee did not ensure that all shifts received quarterly emergency disaster drill. Record showed that only AM/morning staff members received training in April 2026. This poses a potential health and safety risk to clients in care.
POC Due Date: 08/10/2026
Plan of Correction
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Licensee to submit a written plan stating how they will ensure that emergency disaster drills are conducted quarterly for all shifts by POC due date of 08/10/2026.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Victoria Bertozzi
NAME OF LICENSING PROGRAM MANAGER:
Caitlynn Felias
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/29/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/29/2026


LIC809 (FAS) - (06/04)
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