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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486800076
Report Date: 09/20/2022
Date Signed: 09/20/2022 04:17:47 PM

Document Has Been Signed on 09/20/2022 04:17 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 - FIELDSTONEFACILITY NUMBER:
486800076
ADMINISTRATOR:BRENDA SHERIDANFACILITY TYPE:
735
ADDRESS:215 FIELDSTONE COURTTELEPHONE:
(707) 554-1050
CITY:VALLEJOSTATE: CAZIP CODE:
94589
CAPACITY: 6CENSUS: 5DATE:
09/20/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:04 PM
MET WITH:Brenda Lewis, Lead StaffTIME COMPLETED:
04:30 PM
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On 9/20/2022, Licensing Program Analysts (LPA) Tobola conducted an unannounced Annual Required – 1 yr. Infection Control inspection for this facility and met with Lead Staff, Brenda Lewis (BL). The facility currently provides care for 5 clients all of which where present at the time of visit.

LPA arrived at the facility and had temperature checked and logged. LPA continued with a tour of the facility with Lead Staff; 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. LPA measured water temperature at faucets accessible to clients. Water temperature measured between 113.9 and 114.6 degrees F, which is within regulation between 105 and 120 degrees F. Multiple fire extinguishers were located in facility office and laundry area, and found to be last charged on 3/10/2022 at the time of the visit. There was a sufficient supply dishes, silverware and both perishable and nonperishable foods. Food was also found to be stored properly as per Title 22 Regulations.

A shed located in the backyard was observed and found to be locked. Toxins are stored in locked cabinets located in the facility staff office and in the backyard shed. There was a supply of cleaners, hygiene products and paper products available for clients and provided when requested. Staff provide full assistance with hand washing for clients and promoting hygiene health. All client’s bedrooms have lighting & appropriate furnishings. LPA observed backyard fencing to be fully renovated with emergency exits easily accessible.

Continued onto LIC809-C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE: DATE: 09/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/20/2022
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 - FIELDSTONE
FACILITY NUMBER: 486800076
VISIT DATE: 09/20/2022
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Infection Control:
Facility is to submit a infection control plan which has been submitted for review. Posters have been placed at the front door, and facility has a station in the staff office near facility entrance with a sign in sheet, hand sanitizer and other items designated for visitors and staff. Staff and clients are screened for temperature and symptoms on a daily basis and recorded. Clients are also screened for transportation and upon returning from Day Program.

No deficiencies cited during today's inspection.

LPA requested the following documents be sent to CCL by COB 9/27/2022:

LIC 308 Designated Facility Responsibility
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
LIC 9020 Register of Facility Client’s/client’s
Copy of Administrator Certificate(s)
Copy of Liability Insurance
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:

DATE: 09/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2022
LIC809 (FAS) - (06/04)
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