216803761-8-5-2022-21-AS-CFES-CGZS3S-20220805133138

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 216803761
Report Date: 08/05/2022
Date Signed: 08/05/2022 01:31:52 PM

Document Has Been Signed on 08/05/2022 01:31 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:	08/05/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Administrator/Director of Care, Jolly Carungcong		TIME COMPLETED:	01:40 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 10:30AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a 1-year required Annual Visit and met with Administrator, Jolly Carungcong. The inspection is focused on the Infection Control procedures and practices of this facility. Upon arrival at the facility, LPA had their temperature checked and logged. LPA did not answer a COVID-19 Questionnaire. Per conversation with Administrator, Facility stopped using the questionnaire in February 2022. LPA and Administrator discussed the importance of having the questionnaire available to visitors in the event a COVID outbreak occurs. LPA conducted a walk-through of the facility and observed the following: COVID-19 signs were observed at the entry way and throughout the facility. Hand-washing signs were observed in the public bathrooms and at sinks. Hand Sanitizer was readily available for use throughout the facility. Toxins and detergents were secured and inaccessible to residents. Medications were located in the medication room that was locked and inaccessible to residents. All staff present were observed to be wearing a mask. The facility was found to be clean and at a comfortable temperature with all exits free from obstruction. LPA and Administrator discussed facility's plan for staffing if a shortage occurred. Facility has a cleaning and disinfecting schedule that occurs two to three times per day. Facility has at least a 30-day supply of PPE and medication for residents. Staff and residents are screened daily for COVID-19 symptoms and it is logged into facility binders. LPA and Administrator discussed PIN-22-13-ASC regarding Infection Control Plans. Continued on LIC 809-C

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 08/05/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2022

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: 08/05/2022

NARRATIVE

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Continued from LIC 809

LPA observed that 6 of 9 fire extinguishers were last serviced on November 1, 2021. However, 3 of 9 fire extinguishers showed service tags that were outdated, expired, and last serviced on May 6, 2019. Per conversation with Administrator, the Fire Department conducted an inspection in May 2022. LPA was provided with the Fire Department Invoice dated for May 27, 2022 stating that the next extinguisher service will be conducted in November 2022. Administrator called Fire Department during visit to clarify outdated fire extinguisher tags since an inspection was recently conducted. Fire Department will be coming to facility at a later date to check fire extinguishers.

LPA and Administrator discussed the importance of having their fire extinguishers checked yearly per regulation.

Fire Alarms and Carbon Monoxide detectors were last tested during a fire drill conducted on 4/11/2022. Facility has a central pull fire alarm system that is directly connected to the Fire Department. LPA provided with a copy of Fire Drill form.

LPA Felias requested the following documents to update facility file:

Copy of Lease
Copy of Liability Insurance Certificate
Copy of Personnel Report (LIC 500)
Copy of Surety Bond (LIC 402) if appliable

Documents requested to be submitted by Close of Business on Friday, September 2, 2022.

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. Plan of Corrections reviewed and developed with Administrator. Copy of report, LIC
9099-D, and Appeal Rights 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: 08/05/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/05/2022 01:31 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: GREENWOOD ASSISTED LIVING	FACILITY NUMBER: 216803761
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/05/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80020(a)

80020 Fire Clearance (a) All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal.
	Deficient Practice Statement
1 2 3 4	This requirement is not met as evidenced by: LPA observed that 3 of 9 fire extinguishers service tags were outdated, expired, and last serviced on May 6, 2019. LPA did observe that 6 of 9 fire extinguishers were current and dated for November 1, 2021. This poses a potential health and safety risk to residents in care.
	POC Due Date: 09/02/2022
	Plan of Correction
1 2 3 4	Licensee to contact Fire Department or Fire Safety company to have the fire extinguishers serviced. Licensee to submit copy of invoice/receipt and pictures of newly dated tags by POC date of 9/2/2022.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 08/05/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2022

LIC809 (FAS) - (06/04)

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