496803910-8-24-2023-21-AS-VBEI-CUZUHW-20230824153633

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496803910
Report Date: 08/24/2023
Date Signed: 08/24/2023 03:36:40 PM

Document Has Been Signed on 08/24/2023 03:36 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:	GREEN HOUSE EAST RCFE		FACILITY NUMBER:	496803910
ADMINISTRATOR:	JUNCO, BRISA		FACILITY TYPE:	740
ADDRESS:	3248 INDIAN ROCK CT		TELEPHONE:	7075442312
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95404
CAPACITY:	6	CENSUS: 5	DATE:	08/24/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Brisa Junco, Administrator		TIME COMPLETED:	03:45 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 (LPAs) Victoria Bertozzi and Helena Rummonds arrived unannounced to conduct an Annual Required inspection and met with Administrator, Brisa Junco. LPAs initiated a tour of the facility around 9:30am and made the following observations: Facility was a comfortable temperature and passageways were free from obstructions. Resident rooms were furnished per regulation. Water temperature in bathrooms used by residents measured at 98 degrees F which is not within the range of 105 to 120 degrees F allowed per regulation. Licensee has contacted their handyman to turn up water heater to ensure it is within regulation. Extra hygiene products and linens were available. Cabinet containing cleaning supplies was locked. Facility has at least two days of perishable and one week of non-perishable foods which appeared to be of quality and stored per regulation. Medications were centrally stored and locked. Emergency food and water supplies are stored in a garage and shed along with Personal Protective Equipment. Fire extinguisher was fully charged and last serviced May 2022. Smoke and Carbon Monoxide detectors located throughout the facility were tested and operational during inspection. Most recent fire/disaster drill was conducted 7/2023. Three staff files and five resident files were reviewed. Staff have required First Aid and CPR certificates. Administrator Certificate for Administrator, Brisa Junco has expired but administrator provided proof that they have submitted renewal documentation to the Department. Medications and medication records were reviewed. Continued on 809-C

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria Bertozzi	TELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:	DATE: 08/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2023

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 08/24/2023 03:36 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: GREEN HOUSE EAST RCFE	FACILITY NUMBER: 496803910
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87463(c)

Reappraisals

(c) The licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, when there is significant change in the resident's condition, or once every 12 months, whichever occurs first, as specified in Section 87467, Resident Participation in Decision Making. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 4 out of 5 residents not having updated reappraisals which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/07/2023
	Plan of Correction
1 2 3 4	Licensee agrees to update appraisals for noted residents and submit self-certification that appraisals are updated no later than POC due date, 9/7/2023

Type B

Section Cited

CCR

87203

87203 Fire Safety All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in 1 out of 1 fire extinguishers not being serviced within the last 12 months which poses a potential safety risk to persons in care.
	POC Due Date: 08/28/2023
	Plan of Correction
1 2 3 4	Licensee agrees to have fire extinguishers serviced no later than POC due date 8/28/2023 and submit proof of service to LPA.

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: Victoria Bertozzi	TELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:	DATE: 08/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2023

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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: GREEN HOUSE EAST RCFE	FACILITY NUMBER: 496803910
	VISIT DATE: 08/24/2023

NARRATIVE

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Continued from LIC809

Licensee/Administrator to submit updates of the following documents by 9/24/2023:

LIC 500 Personnel Summary
Copy of Liability Insurance
LIC 610 Emergency Disaster Plan (If changes)
Infection Control Plan (If changes)

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: Victoria Bertozzi	TELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:	DATE: 08/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2023

LIC809 (FAS) - (06/04)

Page: 4 of 4

Document Has Been Signed on 08/24/2023 03:36 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: GREEN HOUSE EAST RCFE	FACILITY NUMBER: 496803910
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above by having overgrown ivy as well as other debris which poses a potential safety risk to persons in care.
	POC Due Date: 09/07/2023
	Plan of Correction
1 2 3 4	Licensee agrees to submit photos showing all debris has been removed and landscaping is safe for residents no later than POC due date, 9/7/2023.

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: Victoria Bertozzi	TELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:	DATE: 08/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2023

LIC809 (FAS) - (06/04)

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