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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486800076
Report Date: 10/20/2023
Date Signed: 10/20/2023 05:35:42 PM

Document Has Been Signed on 10/20/2023 05:35 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
SANTA ROSA RO, 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: 4DATE:
10/20/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Brenda Lewis, CaregiverTIME COMPLETED:
06:00 PM
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Licensing Program Analyst LPA Carol Fowler conducted an unannounced Annual Required Inspection and met with Caregiver, Brenda Lewis and Ana Rodriguez. LPA observed all walkways and exits to be unobstructed.

The facility was a comfortable temperature and well lit. Extra hygiene products and linens were available and required grab bars were observed, flooring is nonskid. Water temperature in resident's bathrooms measured at 112.8 degrees F which are within acceptable range of 105 to 120 degrees F. Toxins are located in the locked cabinet in the kitchen. Food appears to be stored and prepared properly. There is more than a week supply of nonperishable food items, and two day supply of perishable food items available for the number of clients in the home. LPA observed plenty of fresh fruit and snacks available to clients. Cash resources are handled by facility Licensee. During the inspection LPA observed bedroom number 6 door is missing and needs to be replaces. Fire extinguisher located in the kitchen and hallway were last inspected March 15, 2023 & within regulation. Smoke detectors with combined Carbon monoxide detector were tested and functional. Staff and resident records were reviewed & found them to be current. Staff First Aid certificates are current. Last disaster drill was performed September 19, 2023.

Deficiencies during inspections:
Facility doesn't have an Administrator.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. This report was read & discussed with Administrator Brenda. Appeal rights were provided.

Exit interview conducted and copy of this report and appeals rights provided.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE: DATE: 10/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/20/2023
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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Document Has Been Signed on 10/20/2023 05:35 PM - It Cannot Be Edited


Created By: Carol Fowler On 10/20/2023 at 05:00 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: GRIFFIN FAMILY CARE HOME - FIELDSTONE
FACILITY NUMBER: 486800076

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/20/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85064(b)
85064 (b) All adult residential facilities shall have a certified administrator.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, records review and interview with Staff, the facility did not ensure to have an active administrator for the facility after prior Administrator left which poses an immediate risk to the health and safety of residents in care.
POC Due Date: 11/17/2023
Plan of Correction
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Licensee to ensure there is a qualified Administrator with an active Administrator Certification associated to the facility at all times. Licensee to submit association request for a qualified Administrator and submit proof of new Administrator by POC due date
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Kimberley Mota
LICENSING EVALUATOR NAME:Carol Fowler
LICENSING EVALUATOR SIGNATURE:
DATE: 10/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/20/2023


LIC809 (FAS) - (06/04)
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