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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486800076
Report Date: 11/21/2024
Date Signed: 11/21/2024 12:33:27 PM

Document Has Been Signed on 11/21/2024 12:33 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/
DIRECTOR:
BRENDA SHERIDANFACILITY TYPE:
735
ADDRESS:215 FIELDSTONE COURTTELEPHONE:
(707) 554-1050
CITY:VALLEJOSTATE: CAZIP CODE:
94589
CAPACITY: 6CENSUS: 4DATE:
11/21/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Gabriela Echevarria, Administrator
Brenda Lewis, Supervisor
Ana Rodriguez, Staff
TIME VISIT/
INSPECTION COMPLETED:
12:45 PM
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11/21/2024, Licensing Program Analyst (LPA) Loera conducted an unannounced Annual Required – 1 yr. inspection visit for this facility. Facility has an emergency disaster plan as required. Facility has an infection control plan as required. Facility tends to developmentally disabled adults, ages 18-59 years. All clients were attending day program upon arrival.

At approximately 10:25am, LPA and staff member toured the building and grounds. The facility was found to be at a comfortable temperature. LPA observed a 2 day supply of perishable and 7 day supply of non-perishable food. Refrigerated food was found to be stored in a safe manner being labeled and dated.

Medications were found to be centrally stored. All rooms were equipped with lighting, night stand, and chest of drawers. All rooms were in good repair. Extra hygiene products and linens were available. Water temperature in sinks accessible to clients in care were measured at 111.2 and 111.9 degrees F which is within the range of 105 to 120 degrees F. Fire extinguishers were last inspected 03/2024. Facility has an annual fire safety inspection with the last one conducted 11/09/2023. Facility conducts monthly fire drills with the last one being conducted 11/12/2024. Smoke/Carbon Monoxide detectors located throughout the facility were tested and operational. Sharps and other items that could pose threat if available to clients were located in the kitchen and were found to be secured. LPA conducted spot medication count and found all prescription medication to be properly recorded on the Centrally Stored Medication Record. Client cash was reviewed.

LPA conducted a review of 4 client records. All records had the required documentation.


Continued on LIC809-C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Anthony Loera
LICENSING EVALUATOR SIGNATURE: DATE: 11/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/15/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
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 - FIELDSTONE
FACILITY NUMBER: 486800076
VISIT DATE: 11/21/2024
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LPA conducted review of 4 staff records/training. Upon a review of staff records, LPA found all staff to have required annual and initial training as well as current 1st Aid & CPR certification on file.

No deficiencies cited during today's inspection. Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit:

LIC500- Personnel Report
LIC308- Designation of Responsibility
LIC400- Affidavit Regarding Client/Resident Cash Resources
LIC402- Surety Bond
Liability Insurance

Exit interview conducted with Supervisor and a copy of this report was provided.

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Anthony Loera
LICENSING EVALUATOR SIGNATURE:

DATE: 11/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2024
LIC809 (FAS) - (06/04)
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