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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 280110565
Report Date: 05/19/2023
Date Signed: 05/19/2023 12:31:46 PM

Document Has Been Signed on 05/19/2023 12:31 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: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: 2DATE:
05/19/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:07 AM
MET WITH:Marcia Torres, House ManagerTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA), Jill Nakagawa arrived unannounced at Griffin Family Care Home-Elliott 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. There was one staff on site. The two residents in care were both participating in Day Program from 9-2 PM.

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 15, 2023. Facility smoke detectors were tested and found to be operational during the inspection. Two (2) Carbon monoxide detectors were tested and found to be operational during the inspection. All bathrooms designated for client use at the facility were supplied with individual paper towels and hand soap dispensers.. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present. Hot water temperature measured at 109 degrees, within Title 22 Regulation of 105 to 120 degrees F. 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. 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. Cont. on 809-C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE: DATE: 05/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/19/2023
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: 05/19/2023
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Continued from 809

LPA inspected the backyard and found 2 locked storage sheds which were secured. Both are used for storage of wood, paint and other household supplies.

The facility recently renovated the bathrooms and kitchen with new cabinets, countertops and sinks. Additional lighting was added as well, making the kitchen/dining area a bright and welcoming gathering spot.

There were no deficiencies found at the time of inspection.

LPA requested the following:

Resident Roster
Surety Bond Update
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2023
LIC809 (FAS) - (06/04)
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