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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803837
Report Date: 08/09/2022
Date Signed: 08/10/2022 11:27:55 AM

Document Has Been Signed on 08/10/2022 11:27 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:
08/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
06:35 PM
MET WITH:Laverne CabalquintoTIME COMPLETED:
07:36 PM
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Licensing Program Analyst (LPA) Araceli Canela arrived unannounced to conduct an annual Required-1 year inspection and met with, facility nurse, Laverne Cabalquinto. Administrator was not available during this visit. The annual inspection is focused on the Infection Control procedures and practices of this Adult Residential Facility. There are currently 4 non ambulatory clients in care, no bedridden approval.

LPA toured facility and grounds with Laverne Cabalquinto and observed COVID-19 precaution signs posted in common areas to promote hand washing, wearing a mask and cough etiquette. Visitors are screened for COVID-19 symptoms upon arrival to the facility. Infection control practices are present: entry procedures, face coverings, daily monitoring and temperatures checked for staff, and clients and facility has 30-day PPE supply. Facility will follow indoor visitation requirement of verifying and tracking COVID-19 vaccination or verify non-essential visitors have proof of a negative COVID-19 test. Facility states staff clean and disinfect the facility daily. Bathrooms are equipped with liquid soap and paper towels. Facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Fire Extinguisher were found to be last charged and serviced on 9/21/2021.

LPA also requested the following updated records to be submitted to Community Care Licensing by 9/9/2022
· LIC 308 Designation of Facility Responsibility
· LIC 500 Personnel Report
· LIC 400 Affidavit Regarding Client/Resident Cash Resources
· LIC 402 Surety Bond
· LIC 610D Emergency Disaster Plan
Exit interview conducted with Laverne Cabalquinto

No deficiencies cited during today's Annual Required 1 YR inspection
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.

LIC809 (FAS) - (06/04)
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