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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803534
Report Date: 07/29/2021
Date Signed: 07/30/2021 10:33:09 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:GREEN MEADOWS LIVING #2FACILITY NUMBER:
496803534
ADMINISTRATOR:BLANCAFLOR, JOSEPHINEFACILITY TYPE:
740
ADDRESS:5525 CARRIAGE LANETELEPHONE:
(707) 791-3172
CITY:SANTA ROSASTATE: CAZIP CODE:
95403
CAPACITY:5CENSUS: 5DATE:
07/29/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Josephine Blancaflor-AdministratorTIME COMPLETED:
03:35 PM
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Licensing Program Analysts (LPA) Dina Alviso arrived unannounced to conduct an Annual Required inspection and met with Licensee/Administrator Josephine Blancaflor. The inspection is focused on the Infection Control procedures and practices of this facility.

Facility has an approved dementia plan of operation. There is an approved hospice waiver for one(1) resident. Mitigation plan was reviewed by the Department LPA on 6/5/21. Fire clearance is approved for five (5) non-ambulatory, of which one(1) can be bedridden. Administrator is contacting emergency equipment services company to ensure fire extinguishers are serviced and tagged as needed per tag.
There were five (5) residents in care at the facility during the inspection. All visitors, essential visitors, and staff are screened upon entry; Temperatures are taken, and screening questions are to be answered before being allowed to remain in the facility, and all information is logged. Residents are screened twice daily, and observed for any changes, all information is logged. Facility was found to be clean, orderly, and at a comfortable temperature with all exits free from obstruction. Toxins are stored in locked cabinets. There was a sufficient supply of hygiene products, cleaners, and paper products for use as needed. Medications were stored locked making them inaccessible to residents in care. All exit alarms were on exit doors and working properly. All bathrooms had grab bars, and non-slip mat/flooring for bathing as needed. All postings were up and visible to all as required. Facility has a sufficient supply of personal protective equipment(PPE). Residents have masks available to them for their use if needed and/or wanted. Administrator stated that staff wear masks in the facility, and also when providing care services to the residents in and out of the facility. Administrator and staff on duty had masks on during the LPA's inspection.
No deficiencies found in the areas inspected.
No citations issued.
Exit interview conducted with the Administrator.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2021
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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