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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486800150
Report Date: 06/13/2024
Date Signed: 06/20/2024 02:09:56 PM

Document Has Been Signed on 06/20/2024 02:09 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 - BERKELEYFACILITY NUMBER:
486800150
ADMINISTRATOR/
DIRECTOR:		GRIFFIN, EDWARD & JOETTAFACILITY TYPE:
735
ADDRESS:673 BERKELEY WAYTELEPHONE:
(707) 422-8423
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 6CENSUS: DATE:
06/13/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Elaine Villalobos, House ManagerTIME VISIT/
INSPECTION COMPLETED:
05:45 PM
NARRATIVE
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**AMENDED
On June 13, 2024 Licensing Program Analyst (LPA) Julie Florio issued incorrect citations for the handling of cash resources, auditory alarms, and an infection control plan. After further record review and conversations with Licensing Program Manager (LPM), LPA has returned to amend (LIC809 and LIC809Ds) and remove citations due to the facility within compliance.

At approximately 9:45 AM, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to conduct a required 1-year annual inspection and was greeted by Elaine Villalobos, House Manager. Licensee/Administrator, Joetta Griffin did not attend todays inspection. Facility is an Adult Residential Facility with Ambulatory Developmentally Disabled Clients in care. LPA was informed that there are 6-clients in care; 3-clients were away at Day Program, and 3-clients were present during visit.

At approximately 10:00 AM, LPA initiated a tour of the facility with House Manager and observed the following: Facility is a one-story home, was a comfortable temperature, and passageways were free from obstructions. Water temperature in clients' bathrooms measured within the allowable range of 105 to 120 degrees F per Title 22 regulations. LPA observed a supply of clean linens and paper products available to clients. Clients' bedrooms were inspected and observed to have appropriate furnishings as outlined in Title 22 regulations. Cabinets containing cleaning supplies and other items that could pose a risk were locked. Facility has at least two days of perishable food and one week of non-perishable foods. LPA informed House Manager of the need to increase facility's supply of emergency water as there was none observed today. Medications were centrally stored and locked. There is a covered deck and outdoor space for activities in the backyard. LPA observed a supply of games for clients and staff engaged in activities.

Facility's 3 fire extinguishers were observed charged and were last serviced April 2024. Smoke and Carbon Monoxide detectors were tested and operational during inspection. Facility conducts regular monthly disaster drills, and the most recent drill was conducted May 2024. LPA observed the facility missing an infection control plan and requested House Manager to submit one to CCL within 10-days. LPA observed an emergency disaster plan updated in 2024. LPA requested House Manager submit the updated disaster plan to CCL to include an additional alternate relocation spot within 10-days. LPA observed a supply of PPE, emergency supplies, and flashlights, as well as a first aid kit. House Manager states the facility does not have a backup generator.

Continued on LIC809-C...
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE: DATE: 06/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/20/2024
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 21
Document Has Been Signed on 06/20/2024 02:14 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 06/19/2024 01:34 PM


Created By: Julie Florio On 06/13/2024 at 03:53 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: GRIFFIN FAMILY CARE HOME - BERKELEY
FACILITY NUMBER: 486800150

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80077.3(a)
Care for Clients who Lack Hazard Awareness or Impluse Control
(a) If a client requires protective supervision because of running/wandering away, supervision may be enhanced by fencing yards, using self-closing latches and gates, and installing operational bells, buzzers, or other auditory devices on exterior doors to alert staff when the door is opened. The fencing and devices must not substitute for appropriate staffing.

This requirement is not met as evidenced by:
Deficient Practice Statement
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**Report amended -- no deficiencies are being cited.
POC Due Date: 06/20/2024
Plan of Correction
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**Report amended -- no deficiencies are being cited.
Type A
Section Cited
CCR
80070(b)(14)
Client Records
(b) Each record must contain information including, but not limited to, the following: (14) An account of the client's cash resources, personal property, and valuables entrusted as specified in Section 80026.

This requirement is not met as evidenced by:
Deficient Practice Statement
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**Report amended -- no deficiencies are being cited.

POC Due Date: 06/20/2024
Plan of Correction
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**Report amended -- no deficiencies are being cited.
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:Bethany Moellers
LICENSING EVALUATOR NAME:Julie Florio
LICENSING EVALUATOR SIGNATURE:
DATE: 06/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2025


LIC809 (FAS) - (06/04)
Page: 2 of 21
Document Has Been Signed on 06/20/2024 02:15 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 06/19/2024 01:37 PM


Created By: Julie Florio On 06/13/2024 at 03:53 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: GRIFFIN FAMILY CARE HOME - BERKELEY
FACILITY NUMBER: 486800150

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85095.5(c)
Infection Control Requirements
(c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 85022. 

This requirement is not met as evidenced by:
Deficient Practice Statement
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**Report amended -- no deficiencies are being cited.
POC Due Date: 06/20/2024
Plan of Correction
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**Report amended -- no deficiencies are being cited.
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:Bethany Moellers
LICENSING EVALUATOR NAME:Julie Florio
LICENSING EVALUATOR SIGNATURE:
DATE: 06/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2024


LIC809 (FAS) - (06/04)
Page: 4 of 21
Document Has Been Signed on 06/20/2024 02:15 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 06/19/2024 01:38 PM


Created By: Julie Florio On 06/13/2024 at 03:56 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: GRIFFIN FAMILY CARE HOME - BERKELEY
FACILITY NUMBER: 486800150

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80026(e)
Cash resources, personal property, and valuables of clients shall be separate and intact, and shall not be commingled with facility funds or petty cash.

This requirement is not met as evidenced by: LPA observed clients' cas resources commingled with each others fund and facility petty cash which LPA was informed is also used to purchase groceries and supplies for the facility.
Deficient Practice Statement
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**Report amended -- no deficiencies are being cited.

POC Due Date: 06/20/2024
Plan of Correction
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**Report amended -- no deficiencies are being cited.
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:Bethany Moellers
LICENSING EVALUATOR NAME:Julie Florio
LICENSING EVALUATOR SIGNATURE:
DATE: 06/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2024


LIC809 (FAS) - (06/04)
Page: 16 of 21
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 - BERKELEY
FACILITY NUMBER: 486800150
VISIT DATE: 06/13/2024
NARRATIVE
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Continued from LIC809...

At approximately 11:00 AM, LPA reviewed 5 staff files and 6 client files. 5 of 5 staff files reviewed have the required First Aid certificates. Each has current CPR certification as well. LPA observed that 5 of 5 staff files have all the required paperwork in their files, however 1 of 5 files reviewed was missing LIC-501 Personnel Record/Job Application, 1 of 5 was missing proof of a negative TB result, and 2 of 5 were missing LIC503 Physician Health Screening. LPA advised House Manager to submit these documents to CCL within 10 days. 6 of 6 client files had the required paperwork per regulation. However, LPA observed 6 of 6 clients records missing LIC627(c) Consent for Emergency Medical Treatment, and LIC601 ID and Emergency Information forms. LPA informed House Manager that these are required forms and requested House Manager submit them to CCL within 10-days. House Manager coordinates medical and dental visits for the clients and take them to their appointments. 3 of 6 clients are currently on a waiting list with the Regional Center for dental appointments and have not been able to be seen by dentist in over a year.

At approximately 12:30 PM, LPA reviewed medications and medication records which are maintained in compliance with regulation. LPA reviewed P&I monies and logs, which were not organized and maintained according to regulation. LPA informed House Manager of the regulation and cited the deficiency (see LIC809-D). House Manager to complete plan of correction (POC) by due date of 6/21/2024.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 10 days of this visit:

Continued on LIC809-C...
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2024
LIC809 (FAS) - (06/04)
Page: 18 of 21
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 - BERKELEY
FACILITY NUMBER: 486800150
VISIT DATE: 06/13/2024
NARRATIVE
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Continued from LIC809-C...

LPA requested the following updated forms to be submitted to Community Care Licensing by 06/23/2024:
· LIC 500 Personnel Report
· LIC 610D Emergency Disaster Plan
· LIC 9020 Register of Facility Clients
· LIC 9282 Infection Control Plan
- LIC200 Application with updated status as a Corporation
-LIC309 Administrative Organization
-Articles of Incorporation and bylaws

The following deficiencies were observed (see LIC 809-D pages) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiencies and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with House Manager and appeal of rights provided. Signature on form confirms receipt.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2024
LIC809 (FAS) - (06/04)
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