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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803761
Report Date: 08/24/2022
Date Signed: 08/24/2022 11:48:39 AM


Document Has Been Signed on 08/24/2022 11:48 AM - 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 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:
08/24/2022
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Licensee, Mark Bello, Executive Director, Neysa Hinton, Administrators, Charleen Vierra and Jolly Carungcong.TIME COMPLETED:
11:00 AM
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At approximately 10:00AM, the Santa Rosa Regional Office conducted an Informal Meeting via Microsoft Teams. The purpose of the Informal Office meeting was to discuss concerns that have been identified with the operation of this facility.

The following individuals were present during the meeting: Licensing Program Managers (LPMs) Bethany Moellers, Hope DeBenedetti, and Kimberley Mota, Licensing Program Analysts (LPAs), Shannan Hansen and Caitlynn Felias, Licensee, Mark Bello, Executive Director, Neysa Hinton, and Administrators Charleen Vierra and Jolly Carungcong.

The following was discussed:
  • Complaints dated 08/16/2021 and 06/14/2022
  • Ensuring that Hospice Entities are able to access the facility
  • Ensuring that Physician Orders are accommodated for Hospice Residents
  • The Appeal Rights Process for Complaints - Executive Director will be submitting documents in regards to an appeal related to the Complaint dated 06/14/2022. Community Care Licensing (CCL) will process accordingly.

Original signature on file. A copy of this report was emailed to Licensee.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn FeliasTELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:
DATE: 08/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/24/2022
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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