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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 480111708
Report Date: 05/26/2022
Date Signed: 05/26/2022 11:58:23 AM

Document Has Been Signed on 05/26/2022 11:58 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:GRIFFIN FAMILY CARE HOME - SWAN WAYFACILITY NUMBER:
480111708
ADMINISTRATOR:GRIFFIN, JOETTAFACILITY TYPE:
735
ADDRESS:115 SWAN WAYTELEPHONE:
(707) 552-6346
CITY:VALLEJOSTATE: CAZIP CODE:
94589
CAPACITY: 6CENSUS: 6DATE:
05/26/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Alex Macajola, House ManagerTIME COMPLETED:
12:00 PM
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Licensing Program Analysts (LPA) Tobola conducted an unannounced Annual Required – 1 yr. Infection Control inspection for this facility and met with House Manager Alex Macajola (AM). The facility currently provides care for 6 clients 2 of which were at day program 1 of which at home visit and 3 of which were present during the inspection.

LPA arrived at the facility and had temperature checked and logged. LPA continued with a tour of the facility with the House Manager; facility was found to be clean and at a comfortable temperature with all exits free from obstruction. LPA observed kitchen found to be fully renovated and in clean condition. Client’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguishers were found to be last charged on 3/18/2022 at the time of the visit. 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 on this day at the time of the visit. Toxins are stored in a locked facility staff office. There was a supply of cleaners, hygiene products and paper products available for clients. Staff provide full assistance with hand washing for clients. All client’s bedrooms have lighting & appropriate furnishings. LPA observed window screens to have fallen located by the dinning room and laundry room. Hot water measured between 110.5 and 111.3 degrees F which is within Title 22 regulations of 105 to 120 degrees F in faucets used by residents.

LPA observed a large hole in client C1's bedroom. Upon record review LPA found that client (C1) demonstrates behaviors of self injurious behavior and damaging the wall. LPA and House Manager discussed possible options to assist with property damage and managing behaviors. LPA also observed fist sized hole located on the kitchen door which LPA was informed will be repaired.

Continued onto LIC809-C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE: DATE: 05/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/26/2022
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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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: GRIFFIN FAMILY CARE HOME - SWAN WAY
FACILITY NUMBER: 480111708
VISIT DATE: 05/26/2022
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LPA requested the following documents be sent to CCL by COB 6/2/2022:

LIC 308 Designated Facility Responsibility
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
LIC 9020 Register of Facility Client’s/Resident’s
Copy of Administrator Certificate(s)
Copy of Certificate of Liability Insurance

Infection Control:
Facility has submitted a mitigation program plan which has been reviewed and approved. Posters have been placed at the front door, and facility has a station at main entrance with a sign in sheet, hand sanitizer and other items designated for visitors and staff. Staff and residents are screened for temperature and symptoms on a daily basis and recorded. All facility staff and clients have received full vaccination and booster.

Appeal Rights Given.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:

DATE: 05/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2022
LIC809 (FAS) - (06/04)
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