<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496801812
Report Date: 06/20/2024
Date Signed: 06/20/2024 03:34:13 PM


Document Has Been Signed on 06/20/2024 03:34 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:GREEN ACRES MANORFACILITY NUMBER:
496801812
ADMINISTRATOR:ISABEL MELANSONFACILITY TYPE:
740
ADDRESS:9020 SONOMA HWY 12TELEPHONE:
(707) 833-1171
CITY:KENWOODSTATE: CAZIP CODE:
95452
CAPACITY:16CENSUS: 13DATE:
06/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Administrator Isabel MelansonTIME COMPLETED:
03:48 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 Analyst (LPA) Christi Coppo arrived unannounced to conduct a required Annual inspection and was greeted by caregiver. Administrator Isabel Melanson arrived later at approximately 10:00am. Facility contact information was reviewed.

At approximately 9:30am LPA and caregiver toured the building and grounds. Admin joined tour at approximately 10:00am. The facility was found to be clean and at a comfortable temperature. LPA observed at least a 2 day supply of perishable and 7 day supply of non-perishable food. The following observations were made of food stored in pantry: tomatoes in bin had black spots, white film, and bluish greenish fuzzy film surrounded by white substance. Storage bin containing canned good had sticky brown film and brown substance with orange film on some cans. Open ziploc bag of lentils, lentils spiling out into bin. Macaroni and cheese box with best when used by date of 3/20/2023 (deficiency cited, see 809D). Kitchen had block of knives open and accessible when half door to kitchen is left open. LPA observed on three occasions during inspection that half door to kitchen was left unlocked, making knives accessible to residents in care (deficiency cited, see 809D). Per LPA conversation with Admin, Admin to move sharp knives to locked drawer. LPA and caregiver observed broken cabinet lock in long hall laundry room, cabinet contained toxins and cleaning supplies. Admin advised LPA that the broken lock is scheduled to be replaced by repairman and laundry room door remains locked at all times.

All bedrooms were equipped with lighting, night stand, and chest of drawers. However, R1 in room #10 did not have bed present. R1's pre-appraisal, care plan, and physician's report did not note a preference or an approval for not having a bed (deficiency cited, see 809D). All bedrooms were clean and in good repair. Extra hygiene products and linens were available. Resident bathrooms had required bath mat and grab bars. Water temperature in sinks accessible to residents in care measured at 121.3 degrees F in long hall bathroom (next to room #6), 119.3 degrees F in room #12, 118.7 degrees F in room #11, 118.5 degrees F in room #10, 114.7 degrees F in room #3, and 117.4 in the main bathroom, degrees F all which are within the allowable range of 105 to 120 degrees F except for in the bathroom next to room #6. Admin turned down water heater slightly to bring temperature down to below 120 degrees F.

Continued on 809C...
SUPERVISOR'S NAME: Victoria BertozziTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Christi CoppoTELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:
DATE: 06/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2024
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 11


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: GREEN ACRES MANOR
FACILITY NUMBER: 496801812
VISIT DATE: 06/20/2024
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
Continued from 809...

Four [4] out of [4] fire extinguishers were last inspected 12/7/2023. Smoke/Carbon Monoxide detectors located throughout the facility are serviced by vendor, last serviced 2/19/2024. Per Admin, fire disaster drill conducted last month. However, no documentation of drill conducted was available. LPA confirmed with staff that fire drill was conducted. Admin will keep record of drill documentation going forward. Facility has a backup generator for use during a power outage.



At approximately 11:30am LPA conducted review of 5 staff records. S1, S2, and S3 do not have current 1st Aid/CPR certifications on file (deficiency cited, see 809D). S4 did not have TB clearance on file (deficiency cited, see 809D). S2, S3, and S5 did not have current annual training (deficiency cited, see 809D). At approximately 1:30pm LPA conducted a review of 5 resident records. All required documentation present.

At approximately 2:30pm LPA and Admin conducted a spot check of medication and medication records. Medication is centrally stored in a locked cabinet. No deficiencies

Isabel Melanson Administrator Certificate 7024381740 expires 2/8/2025. LPA and Administrator discussed facility's Infection Control Plan and Emergency Disaster plan. No new updates.



Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit:

LIC500- Personnel Report
Liability Insurance

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with Admin. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.

Exit interview conducted with Administrator and a copy of this report was given

SUPERVISOR'S NAME: Victoria BertozziTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Christi CoppoTELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2024
LIC809 (FAS) - (06/04)
Page: 2 of 11
Document Has Been Signed on 06/20/2024 03:34 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405


FACILITY NAME: GREEN ACRES MANOR
FACILITY NUMBER: 496801812

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(f)
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA and Admin observation and record review, the licensee did not comply with the section cited above in that S4 did not have proof of TB clearance on Health Screen or in file. which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/03/2024
Plan of Correction
1
2
3
4
Facility to submit to CCL picture of completed TB test and clearance for S4 by plan of correction due date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Victoria BertozziTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Christi CoppoTELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:
DATE: 06/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2024
LIC809 (FAS) - (06/04)
Page: 3 of 11


Document Has Been Signed on 06/20/2024 03:34 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405


FACILITY NAME: GREEN ACRES MANOR
FACILITY NUMBER: 496801812

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(a)(3)(A)
Personal Accommodations and Services
(A) A bed for each resident, except that married couples may be provided with one appropriate sized bed. Each bed shall be equipped with good springs, a clean and comfortable mattress, available pillow(s) and lightweight warm bedding. Fillings and covers for mattresses and pillows shall be flame retardant. Rubber sheeting shall be provided when necessary.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA and Admin observation and record review, the licensee did not comply with the section cited above in that R1 in room #10 did not have bed present. R1's pre-appraisal, care plan, and physician's report did not note a preference or an approval for not having a bed which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/27/2024
Plan of Correction
1
2
3
4
Facility to submit to CCL either a care plan update or a note from the family or responsible party for R1 indicating their desire and approval for R1 to not have a bed in their room, by plan of correction due date.
Type B
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA and Admin observation and record review, the licensee did not comply with the section cited above inthat S1, S2, and S3 do not have current 1st Aid/CPR certifications on file which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/05/2024
Plan of Correction
1
2
3
4
Facility to submit to CCL pictures of current 1st Aid/CPR cards or certificates for S1, S2, and S3 by plan of correction due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Victoria BertozziTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Christi CoppoTELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:
DATE: 06/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2024
LIC809 (FAS) - (06/04)
Page: 4 of 11


Document Has Been Signed on 06/20/2024 03:34 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405


FACILITY NAME: GREEN ACRES MANOR
FACILITY NUMBER: 496801812

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA and Admin observation, the licensee did not comply with the section cited above in that S2, S3, and S5 did not have current annual training on file which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/11/2024
Plan of Correction
1
2
3
4
Facility to submit screenshots of completed training on vendor website for S2, S3, and S5 by plan of correction due date. (Admin to inquire with vendor as to how to print a training log for each respective employee showing total number of hours completed with completion date).
Type B
Section Cited
CCR
87555(b)(8)
General Food Service Requirements
(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA, caregiver, and Admin observation, the licensee did not comply with the section cited above in that pantry had tomatoes stored in bin that had black spots, white film, and bluish greenish fuzzy film surrounded by white substance, storage bin containing canned goods had sticky brown film and brown substance with orange film and spots on some cans, open ziploc of lentils, lentils spilling out into bin, macaroni and cheese box with best when used by date of 3/20/2023 which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/27/2024
Plan of Correction
1
2
3
4
Facility discarded tomatoes and macaroni and cheese box. Facility to submit pictures of food storage bin that is clean and free from films and sticky substances by plan of correction due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Victoria BertozziTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Christi CoppoTELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:
DATE: 06/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2024
LIC809 (FAS) - (06/04)
Page: 5 of 11


Document Has Been Signed on 06/20/2024 03:34 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405


FACILITY NAME: GREEN ACRES MANOR
FACILITY NUMBER: 496801812

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(f)(1)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA, caregiver, and Admin observation, the licensee did not comply with the section cited above in that kitchen had block of knives open and accessible when half door to kitchen is left open. LPA observed on three occasions during inspection that half door to kitchen was left unlocked, making knives accessible to residents in care which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/27/2024
Plan of Correction
1
2
3
4
Facility to submit LIC9098 self-certifying knives have been moved and are now stored in a locking cabinet or drawer by plan of correction due date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Victoria BertozziTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Christi CoppoTELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:
DATE: 06/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2024
LIC809 (FAS) - (06/04)
Page: 6 of 11