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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804049
Report Date: 05/09/2024
Date Signed: 05/09/2024 01:39:12 PM


Document Has Been Signed on 05/09/2024 01:39 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:SONOMA GREENS II LLCFACILITY NUMBER:
496804049
ADMINISTRATOR:MARIMBI, MARTHAFACILITY TYPE:
740
ADDRESS:805 COUNTRY CLUB DR.TELEPHONE:
(707) 304-9106
CITY:SONOMASTATE: CAZIP CODE:
95476
CAPACITY:6CENSUS: 6DATE:
05/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:58 AM
MET WITH:Martha Marimbi, AdministratorTIME COMPLETED:
01:52 PM
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Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a required Annual Inspection and was greeted by Administrator Martha Marimbi. Facility contact information was reviewed.

At approximately 9:30am LPA and Admin toured the building and grounds. The facility was found to be clean and at a comfortable temperature. LPA observed at least a 2 day supply of perishable and 7 day supply of non-perishable food. Kitchen drawer with sharp knives locked. Food in kitchen refrigerator was found to be stored in a safe manner with open items covered. Food in storage refrigerator had bag of lettuce filled with brown liquid and browning lettuce heads. LPA and Admin observed all non-perishable goods that were checked in storage area to be years beyond the best if used by date (BIYB). Items include: cans of canned fruit with BIYB date of 2021, 2022, and 2023, cake mixes with BIYB of 2020 and 2022, box of quick oats with BIYB of 2023, can of whole tomatoes with BIYB of 2022, several boxes of macaroni and cheese with BIYB of 2022 (deficiency cited, see 809D).

LPA and Admin observed laundry room soaps and toxins inside locked laundry room. Laundry room has three doors: one for entry, one leading to a bathroom that resident in room #1 utilizes and the other door leads to the hallway. LPA observed the entry door to be locked, LPA observed the two doors leading out to be locked from the inside; however, laundry room could become accessible to residents, if door accidentally left unlocked. Admin to lock up laundry soaps and toxins in standing cabinet present in laundry room as a precaution.

All bedrooms were equipped with lighting, night stand, and chest of drawers. All bedrooms were clean and in good repair. Extra hygiene products and linens were available. Resident bathrooms had required bath mats and grab bars. Water temperature in sink accessible to residents in care measured at 105.6, 105.5 and 105.4 degrees F which is within the allowable range of 105 to 120 degrees F.



Continued on 809C...
SUPERVISOR'S NAME: Victoria BertozziTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Christi CoppoTELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:
DATE: 05/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/09/2024
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: SONOMA GREENS II LLC
FACILITY NUMBER: 496804049
VISIT DATE: 05/09/2024
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Continued from 809C...

Fire extinguishers were last inspected 4/2/2024. Smoke/Carbon Monoxide detectors located throughout the facility were tested and operational as indicated per Santa Rosa Fire Equipment service sticker dated Jan/2024. Facility’s last quarterly disaster drill conducted 2/5/2024.

At approximately 10:15am LPA and Admin observed the following items in need of repair: wooden fence surrounding facility backyard perimeter in disrepair in several different places. LPA and Admin observed vanity in main bathroom to have eroded paint at bottom and exposed particle board with dark brown/black film around the base and in the corner. LPA and Admin observed bathroom in room #3 to has bubbling and lifting linoleum in the left corner by the toilet (deficiency cited, see 809D).

At approximately 12:00pm LPA conducted a review of 6 resident records. Appraisal Needs and Services Plan (ANS) for two [2] out of six [6] residents were over one year old; ANS for R1 was dated 1/30/23 and ANS for R2 was 2/6/2023 (deficiency cited, see 809D).

At approximately 12:30pm LPA conducted review of 5 staff records. Five [5] out of five [5] staff did not have current 1st Aid/CPR certification (deficiency cited, see 809D). Three [3] out of five [5] staff did not have Health Screens (deficiency cited, see 809D).

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.

Martha Marimbi Administrator Certificate 6051254740 expires 3/21/2025. Fees are due. LPA gave Admin LIS printout with PIN to make payment online.

LPA and Administrator discussed facility's Infection Control Plan and Emergency Disaster plan. No new updates.

Continued on 809C(2)...
SUPERVISOR'S NAME: Victoria BertozziTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Christi CoppoTELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2024
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: SONOMA GREENS II LLC
FACILITY NUMBER: 496804049
VISIT DATE: 05/09/2024
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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
Liability Insurance

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 BertozziTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Christi CoppoTELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2024
LIC809 (FAS) - (06/04)
Page: 3 of 8
Document Has Been Signed on 05/09/2024 01:39 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: SONOMA GREENS II LLC
FACILITY NUMBER: 496804049

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA and Admin record review, the licensee did not comply with the section cited above in five [5] out of five [5] staff did not have current 1st Aid/CPR certification which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/10/2024
Plan of Correction
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2
3
4
Facility to submit plan to have all staff complete 1st Aid/CPR certification by plan of correction due date. Addionally, completed 1st Aid/CPR certification for all staff must be completed by 5/24/2024
Section Cited
Deficient Practice Statement
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3
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POC Due Date:
Plan of Correction
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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: Victoria BertozziTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Christi CoppoTELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:
DATE: 05/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/09/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/09/2024 01:39 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: SONOMA GREENS II LLC
FACILITY NUMBER: 496804049

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(f)
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on LPA and Admin record review, the licensee did not comply with the section cited above in that three [3] out of five [5] staff did not have Health Screens which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/23/2024
Plan of Correction
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Facility to have staff members S1, S4, S5 complete a Health Screen by plan of correction due date. Facility submit copies of completed Health Screens for S1, S4, S5 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 BertozziTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Christi CoppoTELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:
DATE: 05/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/09/2024
LIC809 (FAS) - (06/04)
Page: 5 of 8


Document Has Been Signed on 05/09/2024 01:39 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: SONOMA GREENS II LLC
FACILITY NUMBER: 496804049

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/09/2024

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
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Based on LPA and Admin observation, the licensee did not comply with the section cited above in that the wooden fence surrounding facility backyard perimeter is in disrepair in several different places, vanity in main bathroom has eroded paint at bottom and exposed particle board with dark brown/black film around the base and in the corner, bathroom in room #3 to has bubbling and lifting linoleum in the left corner by the toilet which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/30/2024
Plan of Correction
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Facility to repair backyard fence, replace main bathroom vanity, and fix or replace linoleum in bathroom in room #3. Facility to submit pictures of all repairs/replacements 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
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Based on LPA and Admin observation, the licensee did not comply with the section cited above in that refrigerator had bag of lettuce filled with brown liquid and browning lettuce heads. All non-perishable goods checked were years beyond the best if used by date (BIYB) including: cans of canned fruit with BIYB date of 2021, 2022, and 2023, cake mixes with BIYB of 2020 and 2022, box of quick oats with BIYB of 2023, can of whole tomatoes with BIYB of 2022, sereval boxes of macaroni and cheese with BIYB of 2022. which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/16/2024
Plan of Correction
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Facility to go through all canned goods and boxed food items in storage area and discard all items with best if used by date not stamped with year 2024 or greater. Facility to submit LIC9098 self-certifying that all items are now stamped with a best if used by date of 2024 or greater 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 BertozziTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Christi CoppoTELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:
DATE: 05/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/09/2024
LIC809 (FAS) - (06/04)
Page: 6 of 8