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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 480111708
Report Date: 06/08/2023
Date Signed: 06/08/2023 02:31:56 PM

Document Has Been Signed on 06/08/2023 02:31 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: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:
06/08/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:58 AM
MET WITH:Gabby Echeverria , AdministratorTIME COMPLETED:
02:45 PM
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Licensing Program Analysts (LPA) Tobola conducted an unannounced Annual Required – inspection for this facility and was greeted by Direct Support Staff (DSP), Sid Counts. Administrator, Gabby Echeverria was contacted and arrived later in the visit. The facility currently provides care for 6 clients all of which were at day program at the time of the inspection.

LPA arrived at the facility and had temperature checked and logged. LPA continued with a tour of the facility with the DSP; facility was found to be clean and at a comfortable temperature. 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 3/15/2023 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. All client’s bedrooms have appropriate furnishings. Upon inspection LPA found that client (C1) has demonstrated behaviors in which C1 causes damaged to 3 total facility light switches. Facility is aware of the behaviors and has contacted Maintenance Manager for service request. LPA and Administrator spoke with the Maintenance Manager and confirmed the service request.

Continuing the tour, LPA observed several items of the physical plant in need of repair. These items include; wall panelling in client bathrooms in need of replacing, curtain rod leading to the backyard in need of repair, and outdoor deck in need of deep cleaning. Technical violation issued for Buildings & Grounds. LPA discussed plan of corrections with facility staff. Contracted electrician is scheduled to start repairs the same day as in visit, 6/8/2023.

Continued onto LIC809-C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE: DATE: 06/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/08/2023
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: GRIFFIN FAMILY CARE HOME - SWAN WAY
FACILITY NUMBER: 480111708
VISIT DATE: 06/08/2023
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LPA tested all smoke detectors in common areas and client bedrooms, all of which were found to be in order. Carbon monoxide detector was located in the hallway and found to be working. All facility exits and outdoor emergency exits were found to be clear of any obstructions. Medications were located in a secured staff office only accessible with staff key. LPA conducted a spot medication count and found that the facility is properly recording and administering prescribed medications.

LPA conducted a full review of 6 out of 6 client files and found records to be in order. LPA was informed that 1 out of 6 client Physician's Report has been updated this year but awaiting copy from the physician. LPA confirmed with Administrator that an updated report was completed but waiting for it to be provided by the physician. LPA conducted a review of staff files and found that 3 out of 4 staff do not have 1st Aid & CPR certification on file. Facility Administrator is a certified 1st Aid & CPR trainer, and has completed the training with all staff. However, physical facility files are in need of updating. Technical Violation issued. All clients had arrived during the end of the inspection and LPA observed staff assisting clients with settling into the home. Staff and clients were observed to have a positive relationship with staff providing excellent communication and support.

Gaby Echeverria's Administrator Certification 6000975735 is valid through 9/11/2023.

LPA requested the following documents be sent to CCL by COB 7/6/2022:

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

Report was reviewed with Lead DSP Sid Counts and signed.

No deficiencies cited during today's visit.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:

DATE: 06/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2023
LIC809 (FAS) - (06/04)
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