496803534-6-22-2022-21-AS-DALO-CFMS3M-20220622133122

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496803534
Report Date: 06/22/2022
Date Signed: 06/22/2022 01:31:32 PM

Document Has Been Signed on 06/22/2022 01:31 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME:	GREEN MEADOWS LIVING #2		FACILITY NUMBER:	496803534
ADMINISTRATOR:	GARCIA, DAVID W.		FACILITY TYPE:	740
ADDRESS:	5525 CARRIAGE LANE		TELEPHONE:	7077913172
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95403
CAPACITY:	5	CENSUS: 4	DATE:	06/22/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	David Garcia-Administrator		TIME COMPLETED:	01:30 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 Analysts (LPA) Dina arrived unannounced to conduct a Required 1-Year inspection , and met with Licensee/Administrator David Garcia. 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. Administrator is working on the facility's updated/new Infection Control Plan that is due end of the month. Fire clearance is approved for five (5) non-ambulatory, of which one(1) may be bedridden. Fire extinguishers were current, serviced and tagged as required-expires 8/5/22. There were four (4) residents in care at the facility during the inspection. All 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. All screening information is logged. Residents are screened daily, and observed for any changes at all times. 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 bathrooms had grab bars, and non-slip mat/flooring for bathing as needed. Continued on LIC809C...

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 06/22/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2022

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: GREEN MEADOWS LIVING #2	FACILITY NUMBER: 496803534
	VISIT DATE: 06/22/2022

NARRATIVE

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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 and staff on duty had masks on during the LPA's inspection.

LPA observed that the exit alarm on the slider door that leads out to the patio/deck was not on/alarmed, the alarm was turned off. The Administrator turned the alarm back on during the LPA's inspection. All other auditory alarms were working properly. The slider door alarm was turned off and was not able to sound off if opened by staff/residents/visitors. LPA discussed the auditory alarms with the staff, stating to ensure the alarms are on at all times; The facility does have an approved dementia plan. This violation will be cited, 87705 (j), Care of Persons with Dementia, see LIC809D.

LPA observed food items in the facility refrigerator that were no longer of good quality and/or nutritious, food items that were stored inappropriately and or rotting;-see the following: Lunch meat bag opened/used and just left open in the refrigerator, the lunch meat had hard drying edges on it from being left open this way. plastic bag of string beans that were very wilted, dried out, and starting to rot. Celery very wilted, starting to brown, with darker edges. Cabbage looking old, starting to wilt, and dark brown areas forming on the cabbage folds. Leftovers/mixed food item from a meal in a container marked 6/17, the food item was no longer nutritious to consume.. This violation will be cited, 87555(b)(8)(9) General Food Service Requirements, see LIC809D.

LPA is requesting the following documents be updated and submitted to CCL by 6/29/2022: LIC308 - Designation of Administrator Responsibility, Updated Liability Insurance Certificate, 610 Updated Emergency Disaster Plan.

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.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 06/22/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/22/2022 01:31 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: GREEN MEADOWS LIVING #2	FACILITY NUMBER: 496803534
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/22/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Request Denied

Type A

Section Cited

CCR

87555(b)(8)(9)

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. (9) Procedures which protect the safety, acceptability and nutritive values of food shall be observed in food storage, preparation and service. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA's observation, the licensee did not comply with the section cited above in food items stored in the facility refrigerator, food listed in LIC809, lunch meat, vegetables, that were observed to be of no good quality, and/or tohave nutritious value, not to be cooked and served to residents in care., which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 06/23/2022
	Plan of Correction
1 2 3 4	Licensee to ensure all the food items stored in the facility refrigerator are stored appropriately, ensuring all food has nutritious value when consumed and food is of good quality to use/prepare for meals served to residents in care. Submit how the facility will ensure this correction and a plan on how staff will maintain that food items remain to be of good quality/nutritous for the facility's food supply that are for residents in care. POC due 6/23/22.

Type A

Section Cited

CCR

87705(j)

Care of Persons With Dementia 87705(j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA's observation when the Administrator pulled open the slider door, the alarm did not sound off, all of the other auditory alarms were working when checked. The slider door alarm was found to be in the "off" position, and the Administrator turned it back to the "on" position, the licensee did not comply with the section cited above in the slider door exit auditory alarm, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 06/23/2022
	Plan of Correction
1 2 3 4	Licensee to ensure that all auditory exit alarms are in the on position, and working appropriately at all times; Facility does have an approved dementia plan in place. Licensee to submit how the facility staff will ensure the auditory alarms are on at all times and inservice the staff on the exit auditory alarms and facility's dementia plan. POC due 6/23/22. Follow-up with proof of inservice training with all staff no later than 6/28/22.

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	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 06/22/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2022

LIC809 (FAS) - (06/04)

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