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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496801812
Report Date: 06/17/2022
Date Signed: 06/17/2022 01:52:51 PM


Document Has Been Signed on 06/17/2022 01:52 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:GREEN ACRES MANORFACILITY NUMBER:
496801812
ADMINISTRATOR:HANSEN, JOSEPHFACILITY TYPE:
740
ADDRESS:9020 SONOMA HWY 12TELEPHONE:
(707) 833-1171
CITY:KENWOODSTATE: CAZIP CODE:
95452
CAPACITY:15CENSUS: 14DATE:
06/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Care Director, Isabel Melanson and Administrator, Elizabeth LopezTIME COMPLETED:
02:05 PM
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Licensing Program Analyst (LPA) Erik Gonzalez Campos arrived unannounced to conduct a Required-1 Year Inspection. Licensee, Joe Hansen was not available. LPA met with Care Director, Isabel Melanson and Administrator, Elizabeth Lopez. The inspection was focused on the infection control practices and procedures of this facility.

Upon arrival LPA was screened for COVID symptoms and asked to sign in. LPA toured building and grounds with care director. Facility was a comfortable temperature and in good repair. There are 10 private bedrooms and two double bedrooms. A thirteenth bedroom is currently vacant and is set to be converted into a resident bedroom. Door was locked when LPA toured the facility. LPA requested an updated facility sketch designating the occupancy for each room and marking any other existing structures on the facility grounds to be submitted to Community Care Licensing by June 24, 2022.

Residents' emergency contact information has been updated and staff are familiar with 911 procedures and protocols. Toxins are secured and inaccessible. Medications are centrally stored and inaccessible. The facility has a sufficient supply of Personal Protective Equipment (PPE) and hygiene supplies located in outdoor shed. Exit alarms on exit doors were working properly. Facility is conducting COVID-19 surveillance testing per CCL guidelines.

LPA requested licensee/administrator submit the following documents by July 1, 2022: LIC 500, LIC 610E, LIC 9020, LIC 308, Liability Insurance, Admin Certificate, Infection Control Plan

No deficiencies cited during today's inspection. Exit interview conducted with Care Director, Isabel Melanson and Administrator, Elizabeth Lopez.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez CamposTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 06/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/17/2022
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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