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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803837
Report Date: 09/08/2023
Date Signed: 09/08/2023 03:16:26 PM

Document Has Been Signed on 09/08/2023 03:16 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:
09/08/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Fritzie Cube, AdministratorTIME COMPLETED:
03:20 PM
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Licensing Program Analyst (LPA) Araceli Canela conducted an unannounced Annual Required – 1 yr. inspection to this facility and met with Administrator, Fritzie Cube and toured the inside and outside of the facility. There are currently 4 clients living at this home.

LPA Canela made the following observations: facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Client’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was found to be last charged and serviced on 10/5/2022. 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. Facility has plenty of Emergency food boxed and labeled in the garage. 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. There was a supply of hygiene products and paper products available for clients. All client’s bedrooms have lighting & appropriate furnishings. Hot water temperature measured 119 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. Two out of 4 clients go out to Day Program.

Clients files are kept in locked closet next to med cart and staff records are kept locked in office. LPA reviewed 4 out of 4 client files and found them to be organized, with the required forms. LPA reviewed 3 Staff files and staff had the required records, training and proof of CPR/1st aid expiring 2024 and 2025.

LPA went over reporting requirements and emergency preparedness.


Continue report see LIC809-C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE: DATE: 09/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/08/2023
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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: GREENFIELDS HOME
FACILITY NUMBER: 486803837
VISIT DATE: 09/08/2023
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LPA requested the following documents to be submitted to CCL in order to update facility file by 10/07/23:

LIC 308 Designation of responsibility

LIC 500 Personnel Summary

LIC 400 Affidavit Regarding Resident Cash Resources

LIC 402 Surety Bond ( if Applicable)

LIC 610 Emergency Disaster Plan

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

Copy of Deed and/or Lease of Property

Updated facility Sketch

LPA will process the change to show Fritzie Cube as the New administrator of this facility as soon as we receive a copy of the Administrator Certificate.

NO citations issued in the areas inspected.

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE:

DATE: 09/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2023
LIC809 (FAS) - (06/04)
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