496804049-5-9-2023-21-AS-FSAI-CRNRLQ-20230509130730

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496804049
Report Date: 05/09/2023
Date Signed: 05/09/2023 01:07:37 PM

Document Has Been Signed on 05/09/2023 01:07 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:	SONOMA GREENS II LLC		FACILITY NUMBER:	496804049
ADMINISTRATOR:	MARIMBI, MARTHA		FACILITY TYPE:	740
ADDRESS:	805 COUNTRY CLUB DR.		TELEPHONE:	(707) 304-9106
CITY:	SONOMA	STATE: CA	ZIP CODE:	95476
CAPACITY:	6	CENSUS: 5	DATE:	05/09/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:15 AM
MET WITH:	Licensee/Administrator, Martha Marimbi		TIME COMPLETED:	01:15 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), Farhaan Sarangi arrived unannounced at Sonoma Greens II LLC for the purpose of conducting a Required 1 year inspection. LPA was greeted at the front door by Licensee/Administrator, Martha Marimbi, and was granted access into the facility. Currently, the Administrators Certificate is being processed with the Administrators Certification Section. LPA and Licensee/Administrator toured the facility. LPA observed the facility to be clean and at a comfortable temperature with all exits free from obstruction. Fire Extinguishers were found to be last charged on April 2023 at the time of the inspection. All smoke detectors and carbon monoxide detectors were tested and found to be operational during the inspection. Auditory Devices were operational during the Required 1 year inspection. Emergency Generator was observed in the storage shed in the side of the house. First Aid kit was inspected and found to be appropriate during the inspection. Water temperature in 4 of 4 residents bathroom measured at 110 degrees and is within acceptable range of 105 to 120 degrees F. There was sufficient perishable and non-perishable foods located in the kitchen. Knives and other hazardous items were locked and inaccessible to residents in care. There are special provisions made for individuals with special dietary needs. Food menu was presently available for viewing during the inspection. Activities menu was available for viewing during the inspection. Medications were centrally stored and locked. Medication orders were reviewed for 5 of 5 residents in care and were found to be appropriate during the Required 1 year inspection. Cleaning products and other toxins are located in the locked laundry room and inaccessible to residents in care. There was a supply of Linens, cleaners, hygiene products and paper products available for residents in care during the Required 1 year inspection. All bathrooms designated for residents in the common areas at the facility were supplied with individual paper towels and hand soap. Bathrooms in resident’s rooms have a towel and soap. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present. A tour of all residents bedrooms were conducted, and bedrooms inspected have lighting and appropriate furnishing. (Report continued on LIC 809C)

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan Sarangi	TELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:	DATE: 05/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2023

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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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 II LLC	FACILITY NUMBER: 496804049
	VISIT DATE: 05/09/2023

NARRATIVE

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LPA advised facility to contact County Public Health and Community Care Licensing immediately if symptoms or COVID-19 + or any other infectious diseases in the facility. LPA discussed the Infection Control Plan with the Licensee/Administrator in detail. LPA discussed the Emergency Disaster Plan with the Licensee/Administrator in detail. During the Required 1 year inspection, Licensee/Administrator disclosed to the LPA that the Emergency Disaster drill was last conducted on November 2022 (See LIC 9102-Technical Violation).

During the Required 1 year inspection, LPA reviewed 5 of 5 resident records. However, during one of the resident file reviews, LPA observed 1 out of 5 resident files did not have a current reappraisal. LPA educated the Licensee/Administrator regarding ensuring that Reappraisals are conducted as outlined in regulation (See LIC 9102-Technical Advisory). LPA interviewed 5 of 5 residents in care during the Required 1 year inspection. LPA reviewed 5 of 5 staff member files and found those files to be appropriate during the Required 1 year inspection. LPA interviewed 2 of 2 staff members. All staff providing Care and Supervision currently have First Aid/CPR Card that was reviewed during the staff file review.

LPA requested the following documents to be sent:

LIC 500- Personnel Report
LIC 308- Designation of Responsibility
LIC 309- Administrative Organization
LIC 400- Affidavit regarding Client Cash Resources
Updated facility sketch
Updated Emergency Disaster Plan (LIC 610D)
Surety Bond
Liability insurance
Control of Property
Register of residents
Administrators Certificate

No deficiencies were cited during today's Required 1 year inspection. Exit interview was conducted and a copy of this report was given to the facility Licensee/Administrator.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan Sarangi	TELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:	DATE: 05/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2023

LIC809 (FAS) - (06/04)

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