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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803837
Report Date: 08/24/2021
Date Signed: 08/24/2021 03:42:23 PM

Document Has Been Signed on 08/24/2021 03:42 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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:GREENFIELDS HOMEFACILITY NUMBER:
486803837
ADMINISTRATOR:BADILLO, JASMINE CFACILITY TYPE:
735
ADDRESS:116 MORGAN STTELEPHONE:
(707) 533-2935
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY: 4CENSUS: 4DATE:
08/24/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Assistant Administrator/Facility Mgr of Operations Fritzie CubeTIME COMPLETED:
03:41 PM
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Licensing Program Analyst (LPA) Hansen conducted an unannounced Annual Required – 1 yr. Infection Control inspection to this facility and was met by Staff Ramoncyruz Odon who contacted Assistant Administrator/Facility Mgr. of Operations Fritzie Cube and arrived at facility shortly after. There are 4 clients at the facility..

LPAs arrived at the facility and had her temperature checked and logged. All staff are temperature checked and logged each shift and wear masks. During facility tour on 8/24/2021 with Asst. Admin. Fritzie Cube, facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was found to be last charged on 09/17/2020 at the time of the visit. Smoke Detectors & Carbon monoxide detectors were found to be operational during the visit. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Toxins are stored in a locked closet in the laundry room & under kitchen sink. Medications are stored locked and inaccessible to clients in locked med cart next to kitchen. Clients files are kept in locked closet next to med cart and staff records are kept in locked office. There was a supply of cleaners, hygiene products and paper products available for clients. All client’s bedrooms have lighting & appropriate furnishings. Hot water temperature measured between 115.3 degrees F & 116 degrees F which is within acceptable regulations of 105 to 120 degrees F in client’s bathroom faucets. Facility has outings for clients to parks, and other activities during the day such as gardening and arts & crafts.

Staff 1 has required 1st Aid and CPR certificates, with expiration date of 01/03/2022, S2 has requirements through 03/10/2023, S3 has requirements through 05/2023, & S4 has requirements through 05/2022.

Infection Control:
Facility has submitted a mitigation program plan that has been approved. Posters have been placed at facility and entrance has small table with hand sanitizer and other items designated for visitors and staff before coming into work. Facility has PPE supply stored in kitchen, laundry room & garage. Facility has a 30-day supply of medication for clients. Clients are not wearing masks inside the facility, however; staff stated that they are able to wear masks when going on outings. All staff had masks on during this visit. Asst. Administrator stated all staff are required to be vaccinated prior to hiring and are being tested weekly.
Continued LIC809-C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE: DATE: 08/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/24/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME: GREENFIELDS HOME
FACILITY NUMBER: 486803837
VISIT DATE: 08/24/2021
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In addition, facility has a designated area in the backyard for visitors which are being allowed for scheduled visits. Clients have also available Zoom, Facetime, and telephone calls when contacting with family members and others. Staff had PPE training required on file and have had N-95 fit testing.

LPA reviewed Licensing Information System (LIS) with administrator who stated phone number is incorrect on LIS, which needs to be changed to 707-563-5151 other number is 707-553-2935. In addition, LPA advised facility to contact Local County Public Health and DSS/CCL Community Care Licensing immediately if symptoms or COVID-19 + in the facility. Disaster Drills have been conducted quarterly with the last one being conducted on 8/13/2021.

There were no deficiencies found in the areas inspected.

LPA is requesting the following documents to be submitted to CCL in order to update facility file by 09/07/2021:

LIC 308 Designated

LIC 500 Personnel Summary

LIC 400 Affidavit Regarding Resident Cash Resources

LIC 402 Surety Bond

LIC 610 Emergency Disaster Plan

LIC 9020 Register of Facility Client’s/Resident’s

Copy of Current Administrator's qualifications and Certificate

Copy of Deed and/or Lease of Property

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2021
LIC809 (FAS) - (06/04)
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