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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486800150
Report Date: 05/05/2023
Date Signed: 05/05/2023 05:57:45 PM

Document Has Been Signed on 05/05/2023 05:57 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 - BERKELEYFACILITY NUMBER:
486800150
ADMINISTRATOR:GRIFFIN, EDWARD & JOETTAFACILITY TYPE:
735
ADDRESS:673 BERKELEY WAYTELEPHONE:
(707) 422-8423
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 6CENSUS: 6DATE:
05/05/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:40 PM
MET WITH:Elaine Villalobos, House ManagerTIME COMPLETED:
06:15 PM
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Licensing Program Analyst (LPA) Karina Canela arrived unannounced to conduct a Required - 1 Year inspection and met with Elaine Villalobos, House Manager.
LPA toured the facility with house manager. All exits were unobstructed. Staff and client records were reviewed; Staff have current CPR/first aid certifications in file. 2 fire extinguishers was charged and serviced 03/15/2023. 6 smoke detectors and 1 carbon monoxide detector were tested and observed operational. LPA observed client bedrooms were furnished per regulation. Water temperature was tested and found to be within regulation of 105 to 120 degrees F. Medication was observed locked and inaccessible to clients in care. Detergent and cleaning supplies were observed inaccessible.

LPA requested the following updated forms to be submitted to Community Care Licensing by 06/05/2023:
· LIC 308 Designation of Facility Responsibility (1 person per form)
· LIC 500 Personnel Report
· LIC 400 Affidavit Regarding Client/Resident Cash Resources (indicate if not handling cash for residents)
· Copy of surety bond
· LIC 610D Emergency Disaster Plan
· LIC 9020 Register of Facility Clients
· LIC 9282 Infection Control Plan
· Copy of current Administrator's Certificate

Exit interview conducted with House Manager, whose signature on this document confirms receipt.
***No deficiencies cited during this inspection
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Karina Canela
LICENSING EVALUATOR SIGNATURE: DATE: 05/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/05/2023
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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