486800150-5-19-2026-21-AS-SSTN-DU8QXM-20260519123342

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486800150
Report Date: 05/19/2026
Date Signed: 05/19/2026 12:33:52 PM

Document Has Been Signed on 05/19/2026 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 - BERKELEY		FACILITY NUMBER:	486800150
ADMINISTRATOR/ DIRECTOR:	ELAINE VILLALOBOS		FACILITY TYPE:	735
ADDRESS:	673 BERKELEY WAY		TELEPHONE:	(707) 366-5217
CITY:	FAIRFIELD	STATE: CA	ZIP CODE:	94533
CAPACITY: 6		CENSUS: 3	DATE:	05/19/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:45 AM
MET WITH:	Administrator-Elaine Villalobos		TIME VISIT/ INSPECTION COMPLETED:	12:45 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	At approximately 09:45 AM, Licensing Program Analyst (LPA) Star Stevenson arrived unannounced to conduct arequired 1-year annual inspection and was greeted by Administrator Elaine Villalobos. Facility is an Adult Residential Facility with Developmentally Disabled Clients in care. LPA was informed that there are 6-clients in care; 6-clients were away at Day Programs. Clients are vendored through North Bay Regional Center. Facility has a fire clearance for 6 non-ambulatory clients which none can rely on a wheelchair for mobility due to steps inside the home. Facilities land line was tested and found to be operational. At approximately 10:10 AM, LPA initiated a tour of the facility with administrator and observed the following: Facility is a one-story home, was a comfortable temperature, and passageways were free from obstructions and home was without odors. 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. No expired foods were found and left-over food were clearly labeled with the date they were placed in new air-tight containers or ziplock bags. Facility's 3 fire extinguishers were observed charged and were last serviced March 2026. Smoke and Carbon Monoxide detectors were tested and operational during inspection LPA notes that grasses around the property were cut low to the ground this year to reduce fire risk. Continued on LIC809C

NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Star Stevenson
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/19/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2026

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: GRIFFIN FAMILY CARE HOME - BERKELEY	FACILITY NUMBER: 486800150
	VISIT DATE: 05/19/2026

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Continued from LIC809

At approximately 11:00 AM five (5) of 5 staff files were observed and found to have all required documentation with one employee having a new married name.

Five (5) of six (6) client files were found to have all required documentation and although not a requirement, licensee was advised to ensure that each client has evidence of a signed Consent for Emergency Medical Treatment (LIC627C) on file for each client, signed by themselves or their conservator where appropriate.

P&I monies were found secure (see Griffin Family Care Home P&I Procedures letter on file)

At approximately 11:30 AM LPA and Administrator reviewed the Medication Administration Record (MAR) and record keeping of medicines for two (2) of four (4) clients and although medicine prescriptions and counts were correct, the administration tracking (MAR) was inaccurate with administration not initialed per facility protocol and a Technical Violation is being issued for violation of California Code of Regulations (CCR) 80075(b)(5)(c) and licensee is reminded to make sure a timely record of medicine administration is kept going forward.

The Surety Bond on file recently expired and licensee will need to send evidence of updated Surety insurance.

An updated LIC500 Staff Roster was obtained during today's required inspection.

LPA requested the following documents to update facility file by 06/18/2026 including:
1)Updated LIC610D Emergency disaster plan (9 pages)
2)Updated Surety bond sufficient to cover client resources.

Technical Violation is cited from the California Code of Regulations (CCRs. Failure to correct the cited deficiency may result in a civil penalty assessment in the future.

This report was reviewed with Administrator Elaine Villalobos and Appeal rights were given.

NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Star Stevenson
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/19/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2026

LIC809 (FAS) - (06/04)

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