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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496801936
Report Date: 11/27/2023
Date Signed: 11/27/2023 03:58:22 PM

Document Has Been Signed on 11/27/2023 03:58 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:LOVEJOY'S GREENHOUSEFACILITY NUMBER:
496801936
ADMINISTRATOR:LOVEJOY, MARTHAFACILITY TYPE:
740
ADDRESS:3260 HIDDEN VALLEY DRIVETELEPHONE:
(707) 526-7321
CITY:SANTA ROSASTATE: CAZIP CODE:
95404
CAPACITY: 6CENSUS: 3DATE:
11/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:10 PM
MET WITH:Licensee/Administrator, Martha LovejoyTIME COMPLETED:
04:08 PM
NARRATIVE
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Licensing Program Analyst (LPA) Victoria Bertozzi arrived unannounced to conduct an Annual Required inspection and was met by staff. Licensee/Administrator, Martha Lovejoy came later but was unable to stay. Caregiver was given permission to sign report.

LPA initiated a tour of the facility around 12:30pm and made the following observations: Facility was a comfortable temperature and passageways were free from obstructions. Resident rooms were furnished per regulation. Water temperature in bathrooms used by residents measured at 109 and 116 degrees F which are within the range of 105 to 120 degrees F allowed per regulation. Extra hygiene products and linens were available. Cabinet containing cleaning supplies was locked. Facility has at least two days of perishable and one week of non-perishable foods which appeared to be of quality and stored per regulation. Medications were centrally stored and locked.

Fire extinguishers were last serviced November 2022. Smoke and Carbon Monoxide detectors located throughout the facility were tested and operational. Licensee does not have record of a fire/disaster drill conducted in the last quarter.

Four staff files and three resident files were reviewed. have required First Aid and CPR certificates. Administrator Certificate for Administrator, Martha Lovejoy has expired but is on the Department's Pending List.

Continued on LIC809C
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Bertozzi
LICENSING EVALUATOR SIGNATURE: DATE: 11/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/27/2023
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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Document Has Been Signed on 11/27/2023 03:58 PM - It Cannot Be Edited


Created By: Victoria Bertozzi On 11/27/2023 at 02:48 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: LOVEJOY'S GREENHOUSE
FACILITY NUMBER: 496801936

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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
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Based on record review, the licensee did not comply with the section cited above in 2 out of 4 caregivers not having active CPR and First Aid Certificates which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/01/2023
Plan of Correction
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Licensee will submit proof that noted caregivers have valid First Aid Certificates no later than 12/1/2023. Any staff that work alone are also required to have valid CPR Certificates and Licensee will provide proof of CPR Certificates for those staff no later than 12/1/2023.
Type B
Section Cited
CCR
87412(c)(2)
87412 (c) Licensees shall maintain in the personnel records verification of required staff training and orientation. (2) Documentation of staff training shall include: (A) Trainer’s full name; (B) Subject(s) covered in the training; (C) Date(s) of attendance; and (D) Number of training hours per subject...

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 2 out of 4 caregivers not having sufficiently documented training which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/01/2023
Plan of Correction
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Licensee agrees to submit self-certification that they have read and understand regulations 87411, 87412 and Health and Safety Codes §1569.625 and 1569.69 no later than POC due date, 12/1/2023
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:Hope DeBenedetti
LICENSING EVALUATOR NAME:Victoria Bertozzi
LICENSING EVALUATOR SIGNATURE:
DATE: 11/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/27/2023


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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: LOVEJOY'S GREENHOUSE
FACILITY NUMBER: 496801936
VISIT DATE: 11/27/2023
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Continued from LIC809

Licensee/Administrator to submit updates of the following documents by 11/27/2022:
LIC 308 Designated Administrator (if applicable)
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan (review and update if changes)
Infection Control Plan (if changes)
Liability Insurance

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Bertozzi
LICENSING EVALUATOR SIGNATURE:

DATE: 11/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/27/2023
LIC809 (FAS) - (06/04)
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