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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803837
Report Date: 09/30/2024
Date Signed: 10/03/2024 11:06:35 AM

Document Has Been Signed on 10/03/2024 11:06 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/
DIRECTOR:		BADILLO, JASMINE CFACILITY TYPE:
735
ADDRESS:116 MORGAN STTELEPHONE:
(707) 563-5151
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY: 4CENSUS: 3DATE:
09/30/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:46 PM
MET WITH:Fritzie Cube, AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:47 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. LPA toured the inside and outside of the facility. There are currently 3 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 9/5/2024. Smoke Detectors & Carbon monoxide detectors were found to be operational during the visit. Last emergency/fire drill was conducted and documented on 9/14/2024. There was a sufficient supply of both perishable and nonperishable foods as 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 medication 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 106 degrees F which is within acceptable regulations of 105 to 120 degrees F. Facility has outings for clients to parks, and other activities during the day such as gardening and arts & crafts. Today upon arrival the three clients were out at their Day Program and returned to the facility at about 2:35.

Clients files are kept in locked closet next to medication cart and staff records are kept locked in office. LPA reviewed client files and found them to be organized, with the required forms and current IPP plans. LPA reviewed 3 Staff files and staff had the required records, Health screening, training and proof of CPR/1st aid expiring 2025/2026. Administrator certificate for Fritzie Cube #6067806735 expires 11/12/2025

Continue report see LIC809-C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE: DATE: 09/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/30/2024
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: 09/30/2024
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Required postings were observed. LPA requested the following documents to be submitted to CCL to update our facility file by 10/30/24:

LIC 308 Designation of responsibility

LIC 500 Personnel Summary

LIC 610 Emergency Disaster Plan

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

current facility Sketch

NO citations issued in the areas inspected.

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

DATE: 09/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2024
LIC809 (FAS) - (06/04)
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