<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
280111959
Report Date:
09/09/2022
Date Signed:
09/09/2022 11:13:38 AM
Document Has Been Signed on
09/09/2022 11:13 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:
GREENHILLS CARE HOME, THE
FACILITY NUMBER:
280111959
ADMINISTRATOR:
GANTAN, KAM
FACILITY TYPE:
740
ADDRESS:
115 THAYER WAY
TELEPHONE:
(707) 558-8487
CITY:
AMERICAN CANYON
STATE:
CA
ZIP CODE:
94503
CAPACITY:
24
CENSUS:
23
DATE:
09/09/2022
TYPE OF VISIT:
Case Management - Incident
UNANNOUNCED
TIME BEGAN:
09:30 AM
MET WITH:
Office Admin, Johanne Agcaoila
TIME COMPLETED:
11:00 AM
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
Licensing Program Analyst (LPA) Erik Gonzalez Campos arrived unannounced on 09/09/2022 to conduct a case management inspection regarding a death report received by Community Care Licensing on 09/08/2022. LPA met with Johanne Agcaoila. Administrator and LPA spoke over the phone.
During the inspection LPA conducted interviews and reviewed resident records.
Exit interview conducted with Johanne Agcaoila. A copy of this report was emailed to the licensee.
SUPERVISOR'S NAME:
Kimberley Mota
TELEPHONE:
(707) 588-5051
LICENSING EVALUATOR NAME:
Erik Gonzalez Campos
TELEPHONE:
(707) 588-5026
LICENSING EVALUATOR SIGNATURE:
DATE:
09/09/2022
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
09/09/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809
(FAS) - (06/04)
Page:
1
of
1