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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496801812
Report Date: 08/09/2024
Date Signed: 08/09/2024 11:36:00 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/02/2024 and conducted by Evaluator Christi Coppo
COMPLAINT CONTROL NUMBER: 21-AS-20240802083205
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:
08/09/2024
UNANNOUNCEDTIME BEGAN:
08:57 AM
MET WITH:CaregiverTIME COMPLETED:
11:50 PM
ALLEGATION(S):
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Staff did not keep the facility free of ants
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Christi Coppo arrived at this facility unannounced, to open an investigation into the above allegation. Administrator was not available to come to the facility but was available by phone and allowed for caregiver to sign reports.

Complaint alleges facility not free of ants. LPA observed ants present in resident bathroom in facility. The ants were observed to be coming out of the sink itself and crawling up toward the light switch. Per staff interview, facility is aware of ants, has ant baits in place and they are changed out every two weeks and Terminix comes every 4-6 months. Per Title 22, regualtion 87303(a) The facility shall be clean, safe, sanitary and in good repair at all times.

Based on LPA's observations, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 & Chapter 8, are being cited on the attached LIC 9099D.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Victoria BertozziTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Christi CoppoTELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:

DATE: 08/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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Control Number 21-AS-20240802083205
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 08/09/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/23/2024
Section Cited
CCR
87303(a)
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87303 Maintenance and Operation (a)The facility shall be clean, safe, sanitary and in good repair at all times.

This requirement was not met by licensee as evidenced by:
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Facility to submit service work order from pest control company along with paid invoice by plan of correction due date.
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Based on LPA observation ants present in resident room in facility, which poses a potential health, safety, and personal rights risk to residents in care.
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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: 08/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2