496803910-8-22-2024-21-AS-CCOO-D8DT2Y-20240822142130

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496803910
Report Date: 08/22/2024
Date Signed: 08/22/2024 02:21:51 PM

Document Has Been Signed on 08/22/2024 02:21 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:	(707) 544-2312
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95404
CAPACITY:	6	CENSUS: 5	DATE:	08/22/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:18 AM
MET WITH:			TIME COMPLETED:	02:36 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 Analyst (LPA) Christi Coppo arrived unannounced to conduct a required Annual inspection and was greeted by caregiver. Administrator Brisa Junco arrived later. Facility contact information was reviewed. At approximately 9:30am LPA and Admin toured the building and grounds. The facility was found to be at a comfortable temperature. LPA observed at least a 2 day supply of perishable and 7 day supply of non-perishable food. Food items found to be expired were can of turkey gravy with best if used by date of July 2024, frozen cheese with best if used by date of July 2024 and peanut butter with best if used by date of December 2023 (deficiency cited, see 809D). Food items were found to be stored in a safe manner with open items covered. Kitchen cabinet containing cleaning supplies was not locked, bottle of drain cleaner found outside in backyard, cleaning supplies and laundry soaps in unlocked garage, not in a locked cabinet (deficiency cited, see 809D). All bedrooms were equipped with lighting, night stand, and chest of drawers. Bed in room #4 for R1 and bed in the master bedroom for R2 were found to be not clean, containing black debris and brown debris. Bed for R1 found to not have good springs and was not comfortable, very hard and in spots not supported by good springs. Extra hygiene products and linens were available. Resident bathroom had required bath mat and grab bar. Water temperature in sink accessible to residents in care measured at 98.7 degrees F which is not within the allowable range of 105 to 120 degrees F (deficiency cited, see 809D). Cabinet in garage found to have rodent dropping and chewed pieces of paper and board from the cabinet in which the dropping are located. Cabinet with rodent droppings contained items bagged in garbage bags, pillow, shoes and linens. LPA noticed berry bushes in the backyard. Admin advised those are blackberry bushes. LPA had conversation with Admin about rodents and that sometimes blackberries can attract rodents. Continued on 809C...

SUPERVISOR'S NAME: Victoria Bertozzi	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Christi Coppo	TELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2024

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

FACILITY NAME: GREEN HOUSE EAST RCFE	FACILITY NUMBER: 496803910
	VISIT DATE: 08/22/2024

NARRATIVE

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Continued from 809...

Backyard of facility was found to have debris, shovel head, a pair of garden sheers and overgrown dried weeds and plants, presenting a tripping hazard. Backyard fence on all sides in disrepair: exposed nails, loose and missing boards, boards covered in green film in some areas, and a back up generator that is blocking the exit path and partial portion of the gate. Across from the generator in the left hand corner of the front part of the fence is an area that has a constructed space that is now in disrepair: boards missing, stacked up and leaning against the area, boards have piece of metal and exposed nails and screws. Gates on both sides not easily functional: hard to open and push closed, joint bracket and screws loose on left hand side gate. Gate on right hand side of the facility cannot latch properly due to board with gate latch not secured and in disrepair. Left hand back corner portion of fence is missing entirely. (deficiency cited, see 809D).

Fire extinguishers were last inspected 10/12/2023. Smoke/Carbon Monoxide detectors located throughout the facility were tested and operational. Facility’s last quarterly disaster drills were conducted on 6/21/2024. Facility has a backup generator for use during a power outage.

At approximately 11:30am LPA conducted review of 5 staff records. All required documents present, no deficiencies. All First Aid current, all training complete and current.

At approximately 12:30pm LPA conducted a review of 5 resident records. All required documentation present. 1/2 rails on order.

At approximately 1:00pm LPA and Admin conducted a spot check of medication and medication records. Medication is centrally stored in a locked cabinet. No deficiencies.

Brisa Junco Administrator Certificate 7011129740 expires 7/13/2025. All fees current at this time.

Continued on 809C(2)...

SUPERVISOR'S NAME: Victoria Bertozzi	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Christi Coppo	TELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2024

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: 08/22/2024

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Continued from 809C...

Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit:

LIC500- Personnel Report
LIC308- Designation of Responsibility
LIC309- Administrative Organization
Liability Insurance
Mortgage Deed

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with Administrator. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.

Exit interview conducted with Administrator and a copy of this report was given.

SUPERVISOR'S NAME: Victoria Bertozzi	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Christi Coppo	TELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/22/2024 02:21 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: 08/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)

Maintenance and Operation

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 LPA and Admin observation, the licensee did not comply with the section cited above in that cabinet in garage found to have rodent droppings. Backyard of facility was found to have debris, shovel head, a pair of garden sheers and overgrown dried weeds and plants, presenting a tripping hazard. Backyard fence on all sides in disrepair: exposed nails, loose and missing boards, boards covered in green film, and a back up generator that is blocking the exit path and partial portion of the gate. Across from the generator in the left hand corner of the front part of the fence is an area that has a constructed space that is now in disrepair: boards missing, boards stacked up and leaning against the area, boards have piece of metal and exposed nails and screws. Gates on both sides not easily functional: hard to open and push closed, joint bracket and screws loose on left hand side gate. Gate on right hand side of the facility cannot latch properly due to board with gate latch not secured and in disrepair, left hand back corner portion of fence is missing entirely, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/12/2024
	Plan of Correction
1 2 3 4	Facility to clean out the cabinet with rodent droppings and discard all linens stored in cabinet, repair/replace fence so that there are no gaps or spaces such that it would be unsafe for residents, repair/replace gates, remove all hazards such as loose boards, exposed nails and screws, and sharp items from the backyard. Facility to submit photos to CCL showing cabinet that had rodent droppings in it now cleaned out and free of rodent droppings, repaired/replaced fence and gates, all debris has been removed and landscaping is safe for residents no later than plan of correction due date, 9/12/2024.

Type B

Section Cited

CCR

87303(e)(2)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA and Admin observation, the licensee did not comply with the section cited above in that water temperature in sink accessible to residents in care measured at 98.7 degrees F which is not within the allowable range of 105 to 120 degrees F, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/09/2024
	Plan of Correction
1 2 3 4	Facility to submit water temperature log with 2 weeks of water temperature readings that are within regulation. Pictures of water tempertaure to be shown with therometer and thermomter reading present in picture. Log and pictures to be submitted by plan of correction due date.

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: Victoria Bertozzi	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Christi Coppo	TELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/22/2024 02:21 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: 08/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87309(a)

Storage Space

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA and Admin observation, the licensee did not comply with the section cited above in that kitchen cabinet containing cleaning supplies was not locked, bottle of drain cleaner found outside in backyard, cleaning supplies and laundry soaps in unlocked garage, not in a locked cabinet, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/29/2024
	Plan of Correction
1 2 3 4	Facility to conduct training on proper storage of toxins. Facility to either put a lock on the garage door, making the garage inaccessible to residents or put all cleaning and laundry supplies in a locked cabinet inside the garage by plan of correction due date.

Type B

Section Cited

CCR

87555(b)(8)

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. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA and Admin observation, the licensee did not comply with the section cited above in that food items found to be expired were can of turkey gravy with best if used by date of July 2024, frozen cheese with best if used by date of July 2024 and peanut butter with best if used by date of December 2023, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/23/2024
	Plan of Correction
1 2 3 4	Facility discarded all expired items while LPA present. Deficiency cleared.

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: Victoria Bertozzi	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Christi Coppo	TELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2024

LIC809 (FAS) - (06/04)

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