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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803837
Report Date: 05/18/2022
Date Signed: 05/19/2022 09:42:40 AM

Document Has Been Signed on 05/19/2022 09:42 AM - 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:
05/18/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Fritzie CubeTIME COMPLETED:
02:55 PM
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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 there was one staff (S1) providing care to two clients.
LPA reviewed IPP plans and care plan regarding clients needs and staff to client ratio. LPA requested facility to provide information regarding client to staff ratio and what the plan is for a two person assist, to ensure there is sufficient staff to meet the needs of the clients.

LPA went over facilities responsibility regarding mandated reporting requirements and completing and reporting the required reports to Community Care Licensing (CCL) and other outside agencies.
LPA also went over reporting of any Covid cases to Local Public Health and CCL.



No citations issued during todays visit.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE: DATE: 05/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/18/2022
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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