286804176-7-3-2025-21-AS-JFLO-DJ8UPC-20250703154519

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 286804176
Report Date: 07/03/2025
Date Signed: 07/03/2025 03:45:25 PM

Document Has Been Signed on 07/03/2025 03:45 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:	GREENHILLS CARE HOME, THE		FACILITY NUMBER:	286804176
ADMINISTRATOR/ DIRECTOR:	GANTAN, KAMILEE G.		FACILITY TYPE:	740
ADDRESS:	115 THAYER WAY		TELEPHONE:	(707) 558-8487
CITY:	AMERICAN CANYON	STATE: CA	ZIP CODE:	94503
CAPACITY: 24		CENSUS: 23	DATE:	07/03/2025
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	02:25 PM
MET WITH:	Katherine Dizon, Designated Responsible Party		TIME VISIT/ INSPECTION COMPLETED:	03:45 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 2:25 PM, Licensing Program Analyst (LPA) Julie Florio arrived announced to conduct a pre-licensing inspection and was greeted by Katherine Dizon, Designated Responsible Party (DRP). Kamilee G. Gantan, Administrator was contacted via telephone and gave permission to conduct today's inspection with DRP. Administrator arrived at approximately 3:00 PM. This pre-licensing inspection is being conducted for a change of ownership licensing of a Residential Care Facility for the Elderly (RCFE). Fire Clearance has been approved for 20 non-ambulatory and 4 bedridden resident. Administrator applied for a Hospice waiver for 9 which is being reviewed and has a dementia care plan. Licensee/Applicant works with a placement agency. There were 23 residents in care during today's inspection. At approximately 2:35 PM, LPA initiated a tour of the facility with DRP and observed the following: Facility is a one story building, was a comfortable temperature, and passageways were free from obstructions. Water temperatures in residents' bathrooms measured above and below the allowable range of 105 to 120 degrees F per Title 22 regulations. LPA advised DRP to correct the water temperatures and they agreed. LPA observed resident showers with the required non-slip mats and grab bars in place. LPA observed a supply of clean linens, hygiene products, incontinent care products, and paper products available for residents. Hallways are equipped with night lights and residents' bedrooms have all the appropriate furnishings as outlined in Title 22 regulations. There was a sufficient amount of dishes and cooking supplies for resident use with sharps and other hazardous items kept secured in various designated drawers and cabinets as well as under the kitchen sink. Continued on LIC809-C...

NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Julie Florio
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/03/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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: GREENHILLS CARE HOME, THE	FACILITY NUMBER: 286804176
	VISIT DATE: 07/03/2025

NARRATIVE

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...continued from LIC809...

Cabinets in communal areas of the facility containing cleaning supplies and other items that could pose a risk were observed locked. Facility has at least two days of perishable foods, one week of non-perishable foods, and an emergency water supply. LPA observed a sample menu posted in the common area to indicate a healthy and balanced set of meals for residents in care. The facility telephone was tested and is operational. Facility has internet services and an internet access device designated for resident use. Facility has a designated locked centrally stored medication cart. LPA observed the facility's infection control plan, first aid kits, PPE, other emergency supplies, and a generator for emergency preparedness. LPA observed a posted activity schedule and supplies. The gated yard with patio was observed empty. Administrator states that new furniture it already ordered and will be delivered next week. Windows, screens, and blinds are all found to be in good repair.

Facility has several fire extinguishers, which were last inspected 04/2025 and are fully charged. Administrator has posted hard copies of the emergency disaster plan and maps, personal rights information, local ombudsman information, and the CCLD reporting poster in facility communal areas. Staff are cleared and associated under the existing facility and Administrator agreed to associate the staff to the new facility license in Guardian. Licensee has been informed of association and staff transfer process. Medications were observed centrally stored and locked.

Administrator states that Licensee submitted a copy of the facility's lease agreement and liability insurance to the Centralized Application Bureau. LPA observed a facility sketch which accurately reflects the floor plan.

Component III orientation was conducted with the Administrator at facility where they conveyed knowledge and understanding of Title 22 regulations. The pre-licensing evaluation has been completed.

Exit interview conducted with Administrator, whose signature on this document confirms receipt.

NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Julie Florio
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/03/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2025

LIC809 (FAS) - (06/04)

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