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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 280111959
Report Date: 10/20/2023
Date Signed: 10/20/2023 07:23:47 PM


Document Has Been Signed on 10/20/2023 07:23 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:
10/20/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:31 PM
MET WITH:Kam Gantan, AdministratorTIME COMPLETED:
05:12 PM
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Licensing Program Analyst (LPA) Araceli Canela conducted an unannounced Annual Required – 1 yr. inspection to this facility and met with Administrator Kam Gantan. Facility is licensed for 24 residents and it is at full capacity at the moment. Administrator provided LPA with a copy of an approved Hospice Waiver for 6 and LPA will update the facility license. Facility offers activities including exercise, music therapy, art and Bingo.

During facility tour, facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was last inspected on 4/10/2023. Disaster Drills and Emergency Disaster Plan were conducted and last one documented on 9/1/2023. Fire panel was inspected on 9/6/2023.

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. Dangerous items were stored inaccessible to residents. There was a supply of hygiene products and paper products available for residents. Resident bedrooms had most of the required furnishings and some resident rooms were missing a lamp. Hot water temperatures measured between 105 degrees and 120 degrees F within Title 22 acceptable range.

Staff and resident files were reviewed. Staff have the required training and proof of CPR/1st Aid, expiring 9/2024. Medications are locked in medication cabinet and staff and resident files are in the facility office.

Continue report see LIC809-C
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:
DATE: 10/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/20/2023
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: GREENHILLS CARE HOME, THE
FACILITY NUMBER: 280111959
VISIT DATE: 10/20/2023
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During todays visit, LPA requested facility to add lamps to all resident bedrooms.

LPA went over reporting requirements. LPA also went over requirements for Volunteers over the age of 18 years, will require to be fingerprint cleared, associated to the facility and proof of health screening prior to coming in to the facility. Volunteers under the age of 18 years, will require a health screening, but are not required to be finger print cleared as long as they are under 18 years.

Licensee/Administrator to submit the current following documents by 11/20/2023:


· LIC 308 Designation of Facility Responsibility
· LIC 500 Personnel Report- (received copy 10/20/23)
· LIC 400 Affidavit Regarding Client/Resident Cash Resources
· LIC 610E Emergency Disaster Plan (received copy 10/20/23)
· LIC 9020 Register of Facility Residents
Infection Control Plan of Operation (If changes)
Copy of Liability Insurance-
Copy of Administrator Certificate (received copy 10/20/23)

No citations issues
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:

DATE: 10/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2023
LIC809 (FAS) - (06/04)
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