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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803837
Report Date: 08/05/2022
Date Signed: 08/05/2022 05:48:47 PM

Document Has Been Signed on 08/05/2022 05:48 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: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:
08/05/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
04:05 PM
MET WITH:Fritzie CubeTIME COMPLETED:
04:36 PM
NARRATIVE
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Licensing Program Analyst (LPA), Araceli Canela arrived unannounced regarding another matter. LPA was screened upon entrance to facility and staff were wearing mouth coverings.

During today's visit LPA observed the facility is doing construction in the back enclosed/attached patio. Staff S1 explained the area used to be a storage area. The area is enclosed and attached to the facility and not a separate storage unit. The walls were observed to have been removed.
Facility failed to notify LPA of any new construction or alteration.

LPA once again went over reporting requirements and explained to administrator, Jasmine Baldillo by phone conversation regarding the responsibilities of the facility administrator and regulation 85064(e) for Administrator qualifications: The administrator shall be on the premises the number of hours necessary to manage and administer the facility in compliance with applicable law and regulation.
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Deficiencies 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. Appeal rights and this report will be emailed to facility
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE: DATE: 08/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/05/2022
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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Document Has Been Signed on 08/05/2022 05:48 PM - It Cannot Be Edited


Created By: Araceli Canela On 08/05/2022 at 05:05 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
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: GREENFIELDS HOME
FACILITY NUMBER: 486803837

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/05/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/09/2022
Section Cited
CCR
80086(a)

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80086(a) Alterations to Existing Building or New Facilities (a) Prior to construction or alterations, all licensees shall notify the licensing agency of the proposed change.
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Facility to send in written plan regarding the construction plan, what is being done, plan of completion and how clients will be protected against any hazards, heavy noise. POC due date 8/9/2022
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This requirement was not met as evidenced by: During today's inspection, LPA observed construction/alteration and facility failed to notify the department, this is a potential risk to the health and safety of clients in care
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Facility understands they will need to send in a new facility sketch and paperwork for a new fire clearance after the completion.

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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:Kimberley Mota
LICENSING EVALUATOR NAME:Araceli Canela
LICENSING EVALUATOR SIGNATURE:
DATE: 08/05/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/05/2022


LIC809 (FAS) - (06/04)
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