496801812-7-6-2021-21-AS-EGCS-C4NT7F-20210706142840

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496801812
Report Date: 07/06/2021
Date Signed: 07/06/2021 02:28:50 PM

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:	GREEN ACRES MANOR		FACILITY NUMBER:	496801812
ADMINISTRATOR:	HANSEN, JOSEPH		FACILITY TYPE:	740
ADDRESS:	9020 SONOMA HWY 12		TELEPHONE:	(707) 833-1171
CITY:	KENWOOD	STATE: CA	ZIP CODE:	95452
CAPACITY:	14	CENSUS: 12	DATE:	07/06/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:05 AM
MET WITH:	Administrator, Joseph Hansen		TIME COMPLETED:	02:45 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analysts (LPA), Angela Elliott and Erik Gonzalez Campos arrived unannounced to conduct an Annual inspection at approximately 1:05 PM, and met with administrator Joseph Hansen. The inspection is focused on the Infection Control procedures and practices of this facility. Upon entry LPAs were screened for COVID symptoms and asked to sign in by S1. At primary entrance LPAs observed temperature logs and visitor sign-in sheet. LPAs conducted walk through of the facility with administrator and observed COVID postings throughout. Mitigation plan has been submitted and approved by Community Care Licensing (CCL). Facility was a comfortable temperature and exits were free from obstructions. Hand sanitizer is kept throughout the facility. Per administrator, updated infection control guidelines and PINs are communicated to residents and responsible parties through email. Staff have not completed Personal Protective Equipment (PPE) or infection control training. Staff have not been N95 fit tested. High touch surface areas are disinfected daily. Due to current facility census, residents could isolate in their own rooms if they became ill. LPAs confirmed administrator has necessary PPE equipment and supplies to support a resident in isolation. Residents' emergency contact information has been updated and administrator confirmed staff are familiar with 911 procedures and protocols. Toxins are secured and inaccessible in locked laundry room. An adequate supply of medications are stored in a locked cabinet, making them inaccessible to residents. The facility has a sufficient supply of Personal Protective Equipment (PPE) and hygiene supplies located in outdoor shed. All exit alarms on exit doors were working properly. Facility is conducting COVID-19 surveillance testing per CCL guidelines. Continued on LIC 809C

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez Campos	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 07/06/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 4

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: GREEN ACRES MANOR	FACILITY NUMBER: 496801812
	VISIT DATE: 07/06/2021

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Facility is allowing residents to have meals in the dining room and furniture is set up for social distancing. Common areas are also set up for social distancing. LPAs and licensee discussed resident activities which include puzzles, games, crafts, walks, movies and music. Visits are occurring both inside the facility as well as on the outdoor patio area.

Administrator indicated facility is no longer screening residents, LPAs had discussion regarding mitigation plan. If administrator chooses to modify mitigation plan, LPAs requested he submit it to CCL for review. LPAs had discussion regarding face covering to minimize the risk of COVID-19 as outlined in PIN 21-17.

LPAs requested following documents:

Liability Insurance
LIC 500
Current administrator's certificate
Emergency Disaster Plan

No deficiencies cited during this inspection

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez Campos	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 07/06/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2021

LIC809 (FAS) - (06/04)

Page: 2 of 4