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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804049
Report Date: 04/19/2022
Date Signed: 04/19/2022 11:50:03 AM


Document Has Been Signed on 04/19/2022 11:50 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, LLCFACILITY NUMBER:
496804049
ADMINISTRATOR:MARIMBI, MARTHAFACILITY TYPE:
740
ADDRESS:805 COUNTRY CLUB DR.TELEPHONE:
(707) 304-9106
CITY:SONOMASTATE: CAZIP CODE:
95476
CAPACITY:6CENSUS: 5DATE:
04/19/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Administrator, Martha MarimbiTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Erik Gonzalez Campos arrived unannounced on 04/19/2022 to conduct a pre licensing inspection. LPA met with administrator, Martha Marimbi. Currently there are 5 residents in care. LPA observed auditory devices functioning on the front door and on the doors exiting to the backyard.

LPA toured facility with administrator. LPA observed 4 residents in dining area conversing and engaged in activities. The amount of fresh and nonperishable foods was within regulation. Toxins are secured and inaccessible in locked laundry cabinet. Medications are locked and centrally located in hallway closet, first aid kit is located in the same closet. LPA recorded a water temperature of 108.2 degrees which is within regulation of of 105 and 120 degrees F at faucets accessible to residents. Food is available for residents any time of the day. Bathrooms were equipped with necessary grab bars and non-slip floors/mats and had sufficient hygiene products. Fire extinguisher inspected was charged and dated 01/18/2022. Smoke detectors and carbon monoxide detector were operational. LPA observed required postings (LTCO, CCL Complaint poster) in addition to COVID-19 postings. Facility is screening visitors at the front door which includes taking temperatures and requesting vaccination information.

LPA reviewed 5 out of 5 resident files. LPA reviewed physician's reports, resident appraisals and admission agreements. LPA provided guidance to obtain updated admission agreements with new license information. LPA reviewed 4 staff files, 4 out of 4 staff files had current CPR/First Aid Training. LPA provided guidance to administrator on associating staff to the facility.

Comp III performed with administrator. LPA requested proof of liability insurance during visit. LPA will notify application unit to proceed with licensing.

Exit interview conducted with administrator.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez CamposTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 04/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/19/2022
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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