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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496801936
Report Date: 12/17/2024
Date Signed: 12/17/2024 05:49:51 PM

Document Has Been Signed on 12/17/2024 05:49 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/
DIRECTOR:		LOVEJOY, MARTHAFACILITY TYPE:
740
ADDRESS:3260 HIDDEN VALLEY DRIVETELEPHONE:
(707) 526-7321
CITY:SANTA ROSASTATE: CAZIP CODE:
95404
CAPACITY: 6CENSUS: DATE:
12/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:22 PM
MET WITH:caregiverTIME VISIT/
INSPECTION COMPLETED:
06:05 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a required Annual inspection and was greeted by caregiver. Administrator (Admin) Martha Lovejoy has a current certificate #7035932740 expires 6/26/25. Admin was not available to come to the facility, but gave caregiver permission to sign report. Licensee will be changing the Administrator from Martha Lovejoy to new Administrator. Licensee will send in the required paperwork to CCL within 10 business days of this report.

At approximately 2:00pm LPA and caregiver toured the building and grounds. The facility was found to be clean and at a comfortable temperature. Large bay windows in master bedroom are single pane and have some moisture or water pooling in the sills. Window sills and wood border on the bottom are covered in a black film and spots of a black substance are present on the sides of the windows. Licensee will ensure windows are free from black substance before any new residents occupy the master bedroom, as it is not currently occupied.

LPA observed at least a 2 day supply of perishable and 7 day supply of non-perishable food. Food was found to be stored in a safe manner with open items covered. LPA did not observe any fresh fruits or vegetables present. LPA and caregiver discussed adding some fresh fruits and vegetables to the residents' diet so that the food provided is not only processed foods. Kitchen cabinet containing cleaning supplies was locked. Kitchen drawer with sharp knives locked.

All bedrooms were equipped with night stand and chest of drawers. All bedrooms need a lamp. All bedrooms were clean and in good repair. Extra hygiene products and linens were available. Resident bathroom had required bath mat and grab bar. Water temperature in sink accessible to residents in care measured at 123.2 degrees F in room #2 and 123.3 degrees F in room #6, both of which are not within the allowable range of 105 to 120 degrees F (deficiency cited, see 809D)

Continued on 809C...
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE: DATE: 12/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/17/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: 12/17/2024
NARRATIVE
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Continued from 809...

Fire extinguishers were last inspected 12/21/2023, but are showing as charged. Licensee to have fire extinguishers serviced as soon as possible. Smoke/Carbon Monoxide detectors located throughout the facility were tested and operational. Facility’s quarterly disaster drills have not been conducted (deficiency cited, see 809D)

At approximately 3:30pm LPA conducted a review of 2 resident records. R1 did not have TB results on file (deficiency cited, see 809D). R2 had a handwritten information sheet completed by licensee. LPA discussed with licensee that a complete appraisal needs to be completed for each resident both upon move-in and annually thereafter, ideally completed on a LIC form. Half rails present for both residents but neither had doctor's orders on file.

At approximately 4:00pm LPA conducted review of 3 staff records. S1 and S2 did not have any annual training completed (deficiency cited, see 809D). S1 did not have a Health Screen on file and S2 did not have TB clearance/test results on file (deficiency cited, see 809D).

At approximately 4:30pm LPA conducted a spot check of medication and medication records. Medication is centrally stored in a locked cabinet. Over the counter medications found in room #2 medicine cabinet: Simethicone 125mg, hydrocortisone cream 1%, and Benzethonium chloride 0.2% cream (deficiency cited, see 809D).


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, LIC308- Designation of Responsibility, Liability Insurance, and Current Lease

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 caregiver. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with caregiver and a copy of this report was given.

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 12/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2024
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Page: 2 of 10
Document Has Been Signed on 12/17/2024 05:49 PM - It Cannot Be Edited


Created By: Christi Coppo On 12/17/2024 at 05:02 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: 12/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(2)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, the licensee did not comply with the section cited above in that over the counter medications found in room #2 medicine cabinet: Simethicone 125mg, hydrocortisone cream 1%, and Benzethonium chloride 0.2% cream, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/18/2024
Plan of Correction
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Facility immediately removed items from room#2 and put in the locked medicine closet. Deficiency cleared.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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 Bertozzi
LICENSING EVALUATOR NAME:Christi Coppo
LICENSING EVALUATOR SIGNATURE:
DATE: 12/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/17/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/17/2024 05:49 PM - It Cannot Be Edited


Created By: Christi Coppo On 12/17/2024 at 05:02 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: 12/17/2024

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
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Based on LPA observation, the licensee did not comply with the section cited above in that S1 did not have a Health Screen on file and S2 did not have TB clearance/test results on file, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/07/2025
Plan of Correction
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Facility to submit pictures or fax a copy of completed Health Screen for S1 which also shows TB results and a copy of S2's TB clearance or clear chest xray 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 Bertozzi
LICENSING EVALUATOR NAME:Christi Coppo
LICENSING EVALUATOR SIGNATURE:
DATE: 12/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/17/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/17/2024 05:49 PM - It Cannot Be Edited


Created By: Christi Coppo On 12/17/2024 at 05:02 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: 12/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA and caregiver observation, the licensee did not comply with the section cited above in that Water temperature in sink accessible to residents in care measured at 123.2 degrees F in room #2 and 123.3 degrees F in room #6, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/07/2025
Plan of Correction
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Facility to submit one week temperature log with pictures of thermometer reading for sinks in room #2 and #6 showing water temperature within regulaltion by plan of correction due date.
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
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Based on LPA and caregiver observation and record review, the licensee did not comply with the section cited above inthat S1 and S2 did not hjave any annual training completed, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/07/2025
Plan of Correction
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LPA and licensee discussed training materials. Licensee has chosen to chose an approved vendor to adminsiter training. Facility to submit certificates from chosen vendor showing completed annual training for S1 and S2 by plan of correction due date. Topics of trianing to cover topics outlined in regulation.
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 Bertozzi
LICENSING EVALUATOR NAME:Christi Coppo
LICENSING EVALUATOR SIGNATURE:
DATE: 12/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/17/2024


LIC809 (FAS) - (06/04)
Page: 5 of 10
Document Has Been Signed on 12/17/2024 05:49 PM - It Cannot Be Edited


Created By: Christi Coppo On 12/17/2024 at 05:02 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: 12/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87458(b)(1)
Medical Assessment
(b) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the physician's primary diagnosis and secondary diagnosis, if any and results of an examination for communicable tuberculosis, other contagious/infectious or contagious diseases or other medical conditions which would preclude care of the person by the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation and record review, the licensee did not comply with the section cited above in that R1 did not have TB results on file, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/31/2024
Plan of Correction
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Facility to submit proof of TB test clearance and/or clear chest xray by plan of corrrection due date.
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA interview with caregiver, the licensee did not comply with the section cited above in that facility’s quarterly disaster drills have not been conducted, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/31/2024
Plan of Correction
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Facility to conduct disaster drill and submit documentation of drill 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 Bertozzi
LICENSING EVALUATOR NAME:Christi Coppo
LICENSING EVALUATOR SIGNATURE:
DATE: 12/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/17/2024


LIC809 (FAS) - (06/04)
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