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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803761
Report Date: 10/13/2021
Date Signed: 10/13/2021 12:19:27 PM

Document Has Been Signed on 10/13/2021 12:19 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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:GREENWOOD ASSISTED LIVINGFACILITY NUMBER:
216803761
ADMINISTRATOR:LISADIBARTOLO&ANGELAGRENASFACILITY TYPE:
740
ADDRESS:233 WEST END AVETELEPHONE:
(415) 258-1560
CITY:SAN RAFAELSTATE: CAZIP CODE:
94901
CAPACITY: 47CENSUS: 15DATE:
10/13/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Licensee, Mark BelloTIME COMPLETED:
12:30 PM
NARRATIVE
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Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Greenwood Assisted Living for the purpose of a Case Management-Deficiencies inspection. LPA was greeted at the door by Licensee, Mark Bello. LPA was granted access into the facility.

During the complaint investigation dated for August 16, 2021, based on an interview with the Licensee, LPA learned that R1 did sustain a fall and hospitalization that was unreported to Community Care Licensing Division. In addition, both incidents were not documented on an Unusual Incident Report (LIC 624). (See LIC 809D).

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted and appeal rights provided.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE: DATE: 10/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/13/2021
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 10/13/2021 12:19 PM - It Cannot Be Edited

Citations on this Visit Report are Under Appeal!


Created By: Farhaan Sarangi On 10/13/2021 at 07:41 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: GREENWOOD ASSISTED LIVING
FACILITY NUMBER: 216803761

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/13/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Under Appeal
Type B
10/25/2021
Section Cited
CCR
87211

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87211-Reporting Requirements:
(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:
(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case.
(B) Any serious injury as determined by the attending physician and occurring while the resident is under facility supervision.

This requirement was not met as evidenced by:
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Staff will undergo training regarding the Reporting Requirements and provide evidence of that training along with a sign-in sheet. Proof of that training shall be furnished to the Department of Social Services-Community Care Licensing Division by 10/25/2021
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Based on interviews with facility staff and research of incident reports for Greenwood Assisted Living, the facility did not report an Unusual Incident Report (LIC 624) regarding a fall and subsequent hospitalization to the Department. This poses a potential health, safety or personal rights risk to persons in care.
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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
LICENSING EVALUATOR NAME:Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE:
DATE: 10/13/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/13/2021


LIC809 (FAS) - (06/04)
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