496803538-2-11-2022-21-AS-EGCS-CBJPYA-20220211104338

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496803538
Report Date: 02/11/2022
Date Signed: 02/11/2022 10:43:44 AM

Document Has Been Signed on 02/11/2022 10:43 AM - 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:	SONOMA GREENS		FACILITY NUMBER:	496803538
ADMINISTRATOR:	MARIMBI, MARTHA		FACILITY TYPE:	740
ADDRESS:	805 COUNTRY CLUB DRIVE		TELEPHONE:	(707) 483-0998
CITY:	SONOMA	STATE: CA	ZIP CODE:	95476
CAPACITY:	6	CENSUS: 6	DATE:	02/11/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Administrator, Martha Marimbi		TIME COMPLETED:	10:55 AM

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 Analyst (LPA), Erik Gonzalez Campos arrived unannounced to conduct a Required - 1 Year inspection at approximately 9:00 AM, and met with administrator Martha Marimbi. The inspection is focused on the Infection Control procedures and practices of this facility. Upon entry LPA was screened for COVID symptoms and asked to sign in by administrator. At primary entrance LPA observed visitor sign-in sheet. LPA conducted walk through of the facility with administrator and observed COVID postings throughout. Mitigation plan was submitted by licensee and reviewed by Community Care Licensing. Facility was a comfortable temperature and exits were free from obstructions. Hand sanitizer is kept throughout the facility. Per administrator, updated infection control guidelines and PINs are to be posted for visitors. Personal Protective Equipment (PPE) training was provided to staff by hospice services. High touch surface areas are disinfected daily. Due to current facility census residents could isolate in their own rooms if they became ill. Residents are screened daily for symptoms. Residents' emergency contact information has been updated and administrator confirmed staff are familiar with 911 procedures and protocols. Toxins are secured and inaccessible to residents in laundry room. Laundry room has an entrance off of resident's bedroom. LPA provided guidance to ensure door is kept locked. Medications are centrally stored and inaccessible to residents. Facility is conducting COVID-19 surveillance testing per CCL guidelines. Three of four residents have received their booster shot. Two of four staff have received their booster shot. Continued on LIC 809C

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez Campos	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 02/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 2

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: SONOMA GREENS	FACILITY NUMBER: 496803538
	VISIT DATE: 02/11/2022

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
26
27
28
29
30
31
32

Facility is allowing residents to have meals in the dining room and furniture is set up for social distancing. Common areas are also set up for social distancing. LPA and administrator discussed resident activities which include light walks, and coloring. Visitation is currently being allowed indoors.

LPA requested the following documents during the visit:

Personnel Report
Designation of Facility Responsibility
Liability Insurance
Emergency Disaster Plan
Resident Roster

No deficiencies cited during this inspection.

Exit interview conducted with administrator and a copy of this report printed for facility.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez Campos	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 02/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2022

LIC809 (FAS) - (06/04)

Page: 2 of 2