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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 280110565
Report Date: 04/14/2022
Date Signed: 04/14/2022 11:32:42 AM

Document Has Been Signed on 04/14/2022 11:32 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:GRIFFIN FAMILY CARE HOME - ELLIOTFACILITY NUMBER:
280110565
ADMINISTRATOR:ECHEVARRIA, GABRIELAFACILITY TYPE:
735
ADDRESS:2330 ELLIOTT DRIVETELEPHONE:
(707) 552-6346
CITY:AMERICAN CANYONSTATE: CAZIP CODE:
94503
CAPACITY: 6CENSUS: 3DATE:
04/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:House Manager, Marcia TorresTIME COMPLETED:
11:48 AM
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Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Griffin Family Care Home-Elliot for the purpose of conducting a Required 1 year inspection. LPA was greeted at the door by House Manager, Marcia Torres and granted access into the facility.

LPA toured the facility with the House Manager. During facility tour the facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Clients’ medications are stored in a locked cabinet. Facility has a 30 day supply of medication for clients based on pharmacy supply and refill practices. Fire Extinguisher was found to be last charged on March 2022 at the time of the inspection. Facility smoke detectors were tested and found to be operational during the inspection. Carbon monoxide detectors were tested and found to be operational during the inspection. There are emergency lights in many of the fixtures in the common areas of the facility that come on should a power outage occurs. All bathrooms designated for client use at the facility were supplied with individual paper towels and hand soap dispensers. Bathrooms in clients rooms have a towel and soap. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present. Hot water temperature measured at 105 degrees, within Title 22 acceptable regulation of 105 to 120 degrees F in 2 of 2 bathrooms while touring facility. LPA noted the water pressure in the bathroom closest to the master bedroom had minimal water pressure. House Manager indicated that the faucet is being replaced today (See 9102). There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations at the time of the inspection. Menus are available for clients in care. There was a supply of cleaners, hygiene products and paper products available for clients. Hazardous items and toxins were stored inaccessible to clients in care. A tour of all clients bedrooms were conducted, and bedrooms inspected have lighting and appropriate furnishing.

LPA advised facility to contact County Public Health and Community Care Licensing immediately if symptoms or COVID-19 + in the facility. Facility has PPE supply stored in the stock room. Facility is in the process of being N95 Fit tested. (Report continued on LIC 809C)
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE: DATE: 04/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/14/2022
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: GRIFFIN FAMILY CARE HOME - ELLIOT
FACILITY NUMBER: 280110565
VISIT DATE: 04/14/2022
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LPA requested the following documents to be sent to CCL by April 20, 2022:

-LIC 308 Designated Facility Responsibility
-LIC 500 Personnel Summary
-LIC 610 Emergency Disaster Plan
-LIC 610E-S Supplemental Emergency Disaster Plan for RCFE
-LIC 9020 Register of Facility Client’s/Resident’s
-Copy of Certificate of Liability Insurance

No deficiencies were cited during today's Required 1 year inspection. Exit interview was conducted and a copy of this report was emailed to the facility House Manager.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2022
LIC809 (FAS) - (06/04)
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