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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 280111959
Report Date: 10/13/2022
Date Signed: 10/13/2022 03:59:12 PM


Document Has Been Signed on 10/13/2022 03:59 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:GREENHILLS CARE HOME, THEFACILITY NUMBER:
280111959
ADMINISTRATOR:GANTAN, KAMFACILITY TYPE:
740
ADDRESS:115 THAYER WAYTELEPHONE:
(707) 558-8487
CITY:AMERICAN CANYONSTATE: CAZIP CODE:
94503
CAPACITY:24CENSUS: 24DATE:
10/13/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Administrator, Kam GantanTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Erik Gonzalez Campos arrived unannounced on 10/13/2022 to conduct a Required - 1 Year inspection. This inspection is focused on the infection control practices and procedures of this facility. LPA met with administrator, Kam Gantan.

LPA toured building and grounds which were clean and in good repair. Facility is currently at full capacity. Facility has some shared bedrooms. Facility has planned with resident responsible parties to move around residents in case of a positive. Exit alarms on doorways were observed to be working. LPA observed sufficient perishable and non perishable food. High touch surface areas are disinfected daily. Facility staff have been provided with infection control training and N95 fit testing. All residents and staff have been vaccinated/boosted and received the flu shot. Visitors and staff are screened upon entry. Residents are routinely screened for symptoms. Visitation is by appointment only. Visitors are required to rapid test before entering the facility. LPA and administrator discussed CCL guidelines regarding visitation.

LPA requested the following documents be submitted to Community Care Licensing within 30 days of this inspection:

LIC 500 Personnel Report
LIC 9020 Resident Roster
LIC 610 Emergency Disaster Plan
LIC 308 Designation of Facility Responsibility
Evidence of Liability Insurance

Exit interview conducted with Kam Gantan. A copy of this report was emailed to the administrator.

No deficiencies observed during today's inspection.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez CamposTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 10/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/13/2022
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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