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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486800076
Report Date: 11/30/2021
Date Signed: 11/30/2021 12:42:39 PM

Document Has Been Signed on 11/30/2021 12:42 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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:GRIFFIN FAMILY CARE HOME - FIELDSTONEFACILITY NUMBER:
486800076
ADMINISTRATOR:BRENDA SHERIDANFACILITY TYPE:
735
ADDRESS:215 FIELDSTONE COURTTELEPHONE:
(707) 554-1050
CITY:VALLEJOSTATE: CAZIP CODE:
94589
CAPACITY: 6CENSUS: 5DATE:
11/30/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Brenda Sheridan, AdministratorTIME COMPLETED:
12:15 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 Administrator, Brenda Sheridan (BS). The facility currently provides care for 5 clients all of which where out of the facility at the time of visit.

LPA arrived at the facility and had temperature checked and logged. LPA's continued with a tour of the facility with the Administrator; facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Client’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was found to be last charged on 3/10/2021 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 backyard fencing to be in disrepair. LPA spoke with Licensee, Joetta Griffin and was informed that the facility is in contact with neighboring home with repairs started previously in the month. LPA observed materials for beginning stages of repairs supporting fencing. Licensee agrees to provide proof of repairs to LPA by plan of correction date 12/17/2021.

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 near the 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. In addition, facility has client emergency contact information available during inspection.

No deficiencies cited during today's inspection.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE: DATE: 11/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/30/2021
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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