280111959-10-29-2024-21-AS-CARD-DAHQYM-20241029123523

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 280111959
Report Date: 10/29/2024
Date Signed: 10/29/2024 12:35:29 PM

Document Has Been Signed on 10/29/2024 12:35 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, THE		FACILITY NUMBER:	280111959
ADMINISTRATOR/ DIRECTOR:	GANTAN, KAM		FACILITY TYPE:	740
ADDRESS:	115 THAYER WAY		TELEPHONE:	(707) 558-8487
CITY:	AMERICAN CANYON	STATE: CA	ZIP CODE:	94503
CAPACITY: 24	TOTAL ENROLLED CHILDREN: 0	CENSUS: 22	DATE:	10/29/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:00 AM
MET WITH:	Kam Gantan		TIME VISIT/ INSPECTION COMPLETED:	12:45 PM

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At approximately 10:00AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced to conduct a Required-1 Year inspection. LPA met with Administrator Kam Gantan and explained the purpose of the visit. Administrator certificate is current. LPA toured the facility to ensure the health and safety of residents in care. Areas toured include but are not limited to resident rooms, common areas, bathrooms, kitchen, storage areas and back yard. Hot water temperature measured above regulation at resident bathroom faucets. The common areas, bathrooms and kitchen were clean and in good repair. All bedrooms had required furniture, bedding, and lighting. Cooking/dining equipment and utensils were present. Food appears to be stored and prepared properly. Facility has required seven-day non-perishable and two day perishable supply of food. Medication is locked and not accessible. The facility was observed to be at a comfortable temperature. First aid kit was present. Fire extinguishers were fully charged. Smoke detectors are all operational. Carbon Monoxide Detector was present. Fire sprinklers are throughout. All employees requiring background checks are cleared. No pools/bodies of water are on the premises. Facility has been conducting drills every month.

At approximately 10:30AM, LPA reviewed 16 of 16 Staff and 11 of 22 resident files. All resident files contained the required documentation. Staff files reviewed contained evidence of completed annual training. Only 2 of 16 staff files contained First Aid/CPR certification.

LPA received evidence of Liability insurance at the time of visit.

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

This report was reviewed with Kam Gantan and Appeal rights were given.

Bethany Moellers	TELEPHONE: (707) 588-5040
Christopher Arnhold	TELEPHONE: (707) 588-5084
	DATE: 10/29/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2024

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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Document Has Been Signed on 10/29/2024 12:35 PM - It Cannot Be Edited

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(e)(2)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above. Hot water measured above 120 degrees, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 11/08/2024
	Plan of Correction
1 2 3 4	Administrator contacted plumber to adjust hot water heater during visit. Administrator to test hot water temperature twice daily for seven days and submit recorded temperatures to CCL by POC date of 11/08/2024.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher Arnhold	TELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:	DATE: 10/29/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/29/2024 12:35 PM - It Cannot Be Edited

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.618(c)(3)

Other Provisions

(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 14 out of 16 staff files reviewed. Staff did not have current First Aid/ CPR certification, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/29/2024
	Plan of Correction
1 2 3 4	Administrator to submit self certification that staff have current First Aid/ CPR certification to CCL by POC date of 11/29/2024.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher Arnhold	TELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:	DATE: 10/29/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2024

LIC809 (FAS) - (06/04)

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