216803761-10-9-2023-21-AS-CFES-CWFU53-20231009151604

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 216803761
Report Date: 10/09/2023
Date Signed: 10/09/2023 03:16:09 PM

Document Has Been Signed on 10/09/2023 03:16 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:	GREENWOOD ASSISTED LIVING		FACILITY NUMBER:	216803761
ADMINISTRATOR:	JOLLY CARUNGCONG		FACILITY TYPE:	740
ADDRESS:	233 WEST END AVE		TELEPHONE:	(415) 258-1560
CITY:	SAN RAFAEL	STATE: CA	ZIP CODE:	94901
CAPACITY: 47		CENSUS: 18	DATE:	10/09/2023
TYPE OF VISIT:	Case Management - Annual Continuation	UNANNOUNCED	TIME BEGAN:	12:05 PM
MET WITH:	Administrator, Jolly Carungcong		TIME COMPLETED:	03:25 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	At approximately 12:05PM, Licensing Program Analyst (LPA) Felias arrived unannounced to continue a Required 1 Year visit and met with Administrator, Jolly Carungcong. Upon arrival, LPA was informed that there were 18 Residents in care and 6 staff members on-site. At approximately 12:15PM, LPA reviewed the Facility's Staff Roster and found that all staff on-site were background cleared and associated to the facility per regulation. LPA followed up on self-reported incidents that were submitted to Community Care Licensing (CCL). Incident Report 1/SOC-341: CCL received an incident report and SOC-341 on 04/25/2023 and 04/26/2023. The incident report states that on 04/19/2023, Resident 1 (R1) informed Hospice personnel that Staff Member 1 (S1) slapped their leg when they were providing care with Staff Member 2 (S2). Hospice Personnel observed no bruising or visible injury to R1's leg and reported the conversation to Facility's Executive Director. Executive Director conducted an internal investigation. During investigation, R1 reported to Executive Director that Staff Member 3 (S3) was present during the incident. Executive Director conducted interviews with staff members involved and found that on the night of 04/19/2023, S3 was working with S1 and S2 but was not in the room when they were providing care. S3 entered R1's room at a later time to put away laundry. Report continued to state that R1 required a two person assist when provided care, and did not like being changed as their hips hurt. Internal Investigation resulted in facility re-assigning S1 and S2 to different residents. Facility made all appropriate notifications per regulation. LPA discussed R1 with Administrator. Review of R1's Physician Report stated that R1 is bedridden and has a diagnosis of Mild Cognitive Impairment. Review of R1's Care Plan stated that R1 needs assistance with their care and is also being provided hospice services. Per conversation with Administrator, R1 has not had any allegations of abuse since April 2023. Facility reassigned staff members to ensure that R1's preferences are taken into consideration for who provides their care. R1 has had no further complaints regarding their care. Continued on LIC809C

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:	DATE: 10/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2023

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: GREENWOOD ASSISTED LIVING	FACILITY NUMBER: 216803761
	VISIT DATE: 10/09/2023

NARRATIVE

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Continued from LIC809

Incident Report 2: CCL received an incident report on 07/25/2023. The incident report states that on 07/18/2023, Resident 2 (R2) was observed to be in pain and was unable to stand up as normal. Facility notified Responsible Party and R2 was transported to the hospital for further evaluation. Hospital evaluation determined that R2 had a fractured femur. Facility does not know how fracture occurred as previous shifts observed R2 to be walking well and to not be in pain on 07/16/2023 and 07/17/2023. Report also states that R2 went out with family on 07/16/2023 and there were no reports of pain. Facility made all appropriate notifications per regulation.

LPA discussed R2 with Administrator. Review of R2's Physician Report stated that R2 is non-ambulatory with a diagnosis of dementia. Review of R2's Care Plan stated that R2 needs frequent reminders and assistance when ambulating or transferring. As of today, 10/09/2023, R2 returned to the facility in September 2023 but had another fall on 10/08/2023. As of today, R2 is currently out of the facility.

Incident Report 3: CCL received an incident report on 09/25/2023. The incident report states that on 09/19/2023, Resident 3 (R3) had a witnessed fall when being transferred. Facility Administrator conducted an assessment and observed no visible injury. R3 also reported that they were okay but wanted a Tylenol for neck pain. R3 was later found unconscious in the facility's TV room. Facility contacted Emergency Personnel and R3 was taken to the hospital for evaluation. Hospital evaluation determined that R3 had a hip fracture and will be admitted for rehabilitation. Facility made all appropriate notifications per regulation.

LPA discussed R3 with Administrator. Review of R3's Physician Report stated that R3 has a history of stroke which resulted in paralysis of their left side. R3 does not have a diagnosis of Mild Cognitive Impairment or Dementia and is able to communicate their needs. Review of Care Plan stated that R3 needs assistance with care and is able to communicate when they need help. Per conversation with Administrator, Facility plans to conduct a care conference with R3's Responsible Party to update R3's care plan upon their return to the facility.

LPA requested the following documents to update facility file:

Designation of Facility Responsibility (LIC 308)
Emergency Disaster Plan (LIC 610D)
Updated Personnel Report (LIC 500)
Register of Clients/Residents (LIC 9020)
Updated Liability Insurance
Active and Current Administrator Certificate

Continued on LIC809C

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:	DATE: 10/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2023

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: GREENWOOD ASSISTED LIVING	FACILITY NUMBER: 216803761
	VISIT DATE: 10/09/2023

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 26 27 28 29 30 31 32	Continued from LIC809C Facility Documents to be submitted to Community Care Licensing (CCL) by due date of Thursday, 11/09/2023. No Deficiencies cited during visit. Exit interview conducted. Copy of report, and LIC811 (Confidential Names) discussed and provided to Administrator. Signature on form confirms receipt of documents.

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:	DATE: 10/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2023

LIC809 (FAS) - (06/04)

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