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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486803837
Report Date: 08/09/2022
Date Signed: 08/10/2022 11:19:30 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/04/2022 and conducted by Evaluator Araceli Canela
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20220304083253
FACILITY NAME:GREENFIELDS HOMEFACILITY NUMBER:
486803837
ADMINISTRATOR:BADILLO, JASMINE CFACILITY TYPE:
735
ADDRESS:116 MORGAN STTELEPHONE:
(707) 563-5151
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY:4CENSUS: 4DATE:
08/09/2022
ANNOUNCEDTIME BEGAN:
04:43 PM
MET WITH:Laverne CabalquintoTIME COMPLETED:
06:29 PM
ALLEGATION(S):
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Staff are not meeting client's care needs.
Facility is not providing assistance with transportation to appointments.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), A. Canela arrived unannounced, for the purpose of delivering findings regarding the above listed allegations. LPA was screened upon entrance to the facility by staff. LPA toured the inside of this facility with lead LVN, Laverne Cabalquinto. Administrator, Jasmine Baldillo was not present during this visit. LPA previously gathered statements, reviewed and received records.

It was alleged Staff are not meeting client's care needs. LPA received information client C1 was not being assisted to their medical appointments. LPA reviewed email documentation from 2/7/2022 in which the facility was emailed by C1s Mental Health Clinician to confirm an appointment for C1 on 2/8/2022.

Continue report see LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE:

DATE: 08/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 21-AS-20220304083253
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: GREENFIELDS HOME
FACILITY NUMBER: 486803837
VISIT DATE: 08/09/2022
NARRATIVE
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 Facility staff responded that the appointment could not happen because one of their other facilities had tested positive for Covid, and testing would need to be a priority and asked if the appointment could be rescheduled. Client C1 was not assisted to make it to their appointment of 2/8/2022. Review of medical records also showed a visit on 3/23/2022 where the physician had requested C1 obtain fasting lab work prior to next appointment of 4/5/2022. Facility documentation showed C1 did not get fasting lab work done until 4/8/2022 and not prior to follow up visit of 4/5/2022 as the physician had requested. It was also alleged facility is not providing assistance with transportation to appointments. Facility expressed they always give rides to their clients to their appointments, although there was this instance where C1 was not taken to the appointment with their Mental Health Clinician and asked to reschedule it because of reasons stated above.

Based on LPA’s record review & statements received, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED.

The following deficiencies were observed (see LIC 9099D) and 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. Exit interview conducted and appeal of rights provided.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE:

DATE: 08/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 21-AS-20220304083253
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: GREENFIELDS HOME
FACILITY NUMBER: 486803837
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/09/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/11/2022
Section Cited
CCR
85075(b)
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85075(b) Health-Related Services (b) The facility shall develop and implement a plan which ensures that assistance is provided to the clients in meeting their medical and dental needs. This requirement was not met. As evidenced by:
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Facility to send in a written plan on how they will ensure they meet regulation and are following up with clients appoitnments.
POC due date 8/11/2022
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Investigation revealed client C1 was not assisted to make it to their appointment and facility cancelled or could not keep the appt for C1 on 2/8/2022. This is an immediate Health and Safety risk to clients in care.
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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.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE:

DATE: 08/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/04/2022 and conducted by Evaluator Araceli Canela
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20220304083253

FACILITY NAME:GREENFIELDS HOMEFACILITY NUMBER:
486803837
ADMINISTRATOR:BADILLO, JASMINE CFACILITY TYPE:
735
ADDRESS:116 MORGAN STTELEPHONE:
(707) 563-5151
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY:4CENSUS: 4DATE:
08/09/2022
UNANNOUNCEDTIME BEGAN:
04:43 PM
MET WITH:Laverne CabalquintoTIME COMPLETED:
06:29 PM
ALLEGATION(S):
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Medication management is inadequate.
Staff made inappropriate comments re/towards client.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), A. Canela arrived unannounced, for the purpose of delivering findings regarding the above listed allegation. LPA was screened upon entrance to the facility by staff. LPA toured the inside of this facility with lead care staff, Laverne Cabalquinto. Administrator, Jasmine Baldillo was not present during this visit. LPA previously gathered statements, reviewed and received records.

It was alleged Medication management is inadequate, LPA reviewed medication log with documented medication provided to client C1. LPA did not receive any corroborating statements from staff or C1 that medication is not being provided adequetly. It was also reported staff made inappropriate comments re/towards client in that staff verbally abuse C1 and call C1 “fat.”
Staff denied the allegations and C1 did not corroborate it.
Although the allegations may be true, or are valid, there is not a preponderance of evidence to prove the alleged violations did, or did not, occur.Therefore, the allegations above are both UNSUBSTANTIATED. No citations issued today. No citations issued.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE:

DATE: 08/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 4