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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803761
Report Date: 11/17/2022
Date Signed: 11/17/2022 01:11:57 PM


Document Has Been Signed on 11/17/2022 01:11 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 LIVINGFACILITY NUMBER:
216803761
ADMINISTRATOR:JOLLY CARUNGCONGFACILITY TYPE:
740
ADDRESS:233 WEST END AVETELEPHONE:
(415) 258-1560
CITY:SAN RAFAELSTATE: CAZIP CODE:
94901
CAPACITY:47CENSUS: 22DATE:
11/17/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Neysa Hinton, Executive DirectorTIME COMPLETED:
01:30 PM
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LIcensing Program Analyst (LPA) Jill Nakagawa arrived unannounced at Greenwood Assisted Living for the purpose of following up on an incident report that was forwarded to the Regional Office (RO) on October 7, 2022. LPA was greeted at the door by a Staff Member, Kathleen Devera and was granted access into the facility.

During the Case Management Inspection, LPA requested the following documents:

-LIC 602 and Care Plan for R1
-Hospice Notes for R1

No deficiencies were observed or cited during today's Case Management Inspection. Exit interview was conducted and a copy of this report was signed and given to the Executive Director.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:
DATE: 11/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/17/2022
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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