496803534-7-11-2023-21-AS-DALO-CTN2H7-20230711172415

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496803534
Report Date: 07/11/2023
Date Signed: 07/11/2023 05:24:19 PM

Document Has Been Signed on 07/11/2023 05:24 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:	(707) 791-3172
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95403
CAPACITY:	5	CENSUS: 5	DATE:	07/11/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:17 PM
MET WITH:	David Garcia-Administrator		TIME COMPLETED:	05:30 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) Alviso arrived to conduct a Required- 1 Year visit, on 7/11/23 at approximately 2:17pm, and met with Licensee/Administrator David Garcia. Currently there are five(5) residents in care. Facility has an approved dementia plan of operation. There is an approved hospice waiver for one(1) resident. Facility has an emergency disaster plan as required. Facility has an infection control plan as required. Fire clearance is approved for five (5) non-ambulatory, of which one(1) may be bedridden. Fire extinguishers, two(2) were current, serviced and tagged as required- expires 8/6/23. LPA toured the facility with the Administrator. The hot water was checked at 114.9 F, which is within regulation of no higher than 120.F and no lower than 105. F. All exits were unobstructed. All bathrooms, common areas, and resident rooms had sufficient lighting; The hallway had night lights for use. All bathrooms had grab bars, and bath mats/non-skid flooring in showers for resident use. The facility was at a comfortable temperature. Facility had a sufficient supply of cleaners, hygiene products, and paper products. Food supply was sufficient, perishable and nonperishable. The LPA observed sufficient supply of linens, blankets, and towels for resident use. Continued on LIC9099C...

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 07/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2023

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 07/11/2023 05:24 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: 07/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(h)(2)

(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA's observation of many medications out on the dresser, some in lil plastic covered cups, in staff's unlocked bedroom; LPA observed the medications to be accessible to residents in care, the licensee did not comply with the section cited above in centrally storing all medications, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 07/12/2023
	Plan of Correction
1 2 3 4	Licensee/Administrator to ensure all medications are locked up and inaccessible to residents in care at all times. Administrator stated that all staffs medications will be centrally stored, separate from resident medications, in the large medication cabinet which is always kept locked. Administrator to in-service all staff of policies and procedures of centrally stored medications; Submit proof of inservice training by 7/18/23. Plan of correction due 7/12/23.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: 07/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2023

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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: GREEN MEADOWS LIVING #2	FACILITY NUMBER: 496803534
	VISIT DATE: 07/11/2023

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LPA observed medications out on the dresser in staff's unlocked bedroom; LPA's observation of many medications out on the dresser, some in lil plastic covered cups. LPA observed the medications to be accessible to residents in care. This deficiency will be cited, 87465(h)(2) Incidental Medical & Dental Care, The following requirements shall apply to medications which are centrally stored: Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication, see LIC809D.

The LPA will continue this annual inspection at a later date.

Deficiency cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.

Exit interview conducted with the Administrator.
Appeal rights given.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 07/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2023

LIC809 (FAS) - (06/04)

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