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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880899
Report Date: 02/15/2024
Date Signed: 02/15/2024 01:00:30 PM

Document Has Been Signed on 02/15/2024 01:00 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:GREEN WILLOW HOME CAREFACILITY NUMBER:
361880899
ADMINISTRATOR:ROSEMARIE SUMADSADFACILITY TYPE:
740
ADDRESS:950 S WILLOW AVETELEPHONE:
(909) 835-8706
CITY:RIALTOSTATE: CAZIP CODE:
92376
CAPACITY: 6CENSUS: 5DATE:
02/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Jocelyn Santiago, Care StaffTIME COMPLETED:
01:00 PM
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Licensing Program Analyst, Amber Coleman, (LPA) arrived at the Green Willow Home Care Facility unannounced to conduct the Annual Inspection. LPA knocked on the door and was greeted by Care Staff, Jocelyn Santiago and granted entry. LPA introduced self and stated purpose of the visit. Administrator, Rosemarie Sumadsad and Care Staff, Miguelito Veluz arrived later during the visit.

LPA was accompanied by Jocelyn Santiago on a tour inside and outside, and observed the following:

Facility: The Facility is licensed for six (6) non-ambulatory adults, 1 bedridden and a Hospice Waiver for 6 residents. LPA observed that the facility is operating in the capacity and conditions approved by Community Care Licensing (CCL).
Physical Plant: LPA Coleman observed the facility's temperatures to be maintained comfortably. The facility is comprised of 2 Living Rooms, Dining Rooms, Resident/Staff Rooms, Bathrooms, Kitchen, Backyard and attached garage. Resident Room contained all required furnishings. Restrooms are maintained for staff and residents. Each bathrooms included operable appliances, adequate paper supplies, non-slip grip materials and handrails. Extra supplies of linens, towels, hygiene supplies were located in the bathroom and hallways. The facility was sufficiently lit by various lamps and night lights throughout. The facility is equipped with operable fire/smoke alarms, carbon monoxide detectors. Fire Extinguisher was located in the kitchen; fully changed and last inspected January 2024. The facility's Emergency Disaster Plan, Facility Sketch and Evacuation Plan was reviewed; as it was posted in a prominent place.

Kitchen/Food Service: LPA observed the food supply; the amount of nonperishable and perishable food is sufficient for number of residents in care. LPA's visit was during lunch. LPA witnessed food prepared and stored properly. Sharp objects were secure and inaccessible to residents in care.
Please see LIC809-C
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE: DATE: 02/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/15/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: GREEN WILLOW HOME CARE
FACILITY NUMBER: 361880899
VISIT DATE: 02/15/2024
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Garage - In the facility's attached garage, LPA observed the emergency food supply was well stocked. LPA also observed that the facility centrally stores medications securely in this area.
Care & Supervision: Facility has sufficient care staff; who also reside on facility grounds. toxic items are inaccessible to residents in care and stored and locked in a filing cabinet in the office.

Record Review of Resident/Staff Files: LPA reviewed records for all six (6) residents in care. Resident records are all complete with updated Physician's Reports, Admissions Agreements, Appraisals and Needs and Services Plans. LPA reviewed all two (2) staff files. LPA confirmed that staff records reflect current CPR/First Aid Certification, Criminal Record Clearances, Fingerprinting, Personnel Records and Health Screenings. The Administrator's Administrator Certificates were posted and observed in good standing.

Signs/Posters: LPA observed the following signs posted in a prominent place: Facility Sketch Disaster Plan, Long Term Care Ombudsman, Resident Rights, Resident Council, Theft and Loss Policy, Staff Roster, Visiting Hours, Daily Schedule and facility license are posted in the hallway of the facility. Emergency Disaster Plan is current.

Medication/Medical Related Services: LPA observed that the resident's medications are centrally stored and secure in file cabinets in the kitchen and garage. LPA reviewed all the resident's medications and compared it to the facility's Medication Administration Report (MARs) and Centrally Stored Medication Log.

Based on observations, staff interviews and records reviews, no deficiencies were cited during visit. An exit interview was conducted. This report was reviewed, discussed then provided to Facility Representative.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE:

DATE: 02/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2024
LIC809 (FAS) - (06/04)
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