<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604459
Report Date: 08/05/2021
Date Signed: 08/11/2021 04:48:55 PM

Document Has Been Signed on 08/11/2021 04:48 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, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:GREEN VILLAFACILITY NUMBER:
374604459
ADMINISTRATOR:BRODSKY, TATIANAFACILITY TYPE:
740
ADDRESS:6396 LAKE DECATUR AVETELEPHONE:
(619) 465-2518
CITY:SAN DIEGOSTATE: CAZIP CODE:
92119
CAPACITY: 6CENSUS: 6DATE:
08/05/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
02:08 PM
MET WITH:Applicant, Tatiana BrodskyTIME COMPLETED:
04:35 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), Debbie Correia, conducted an announced Pre-licensing and Component IIl visit at a Residential Care Facility for the Elderly (RCFE) to ensure compliance with California Code of Regulations, Title 22, Division 6 and the Health and Safety Code. LPA Correia identified herself to Applicant Tatiana Brodsky and explained the purpose of the visit. The fire inspection was completed on July 8, 2021 by the San Diego Fire Department. Facility was cleared for six residents ages 60 and above, five (5) that may be non-ambulatory, and one (1) of which may be bedridden in a dedicated bedroom.

During today's visit LPA Correia, accompanied by Applicant Brodsky, conducted a tour of the facility. According to Applicant Brodsky there will be no firearms or ammunition stored on site. LPA observed a pool on the premises that is fully fenced and locked. Indoor and outdoor passageways are free from obstructions. All window screens are clean and in good repair. Hallways are well-lit and night lights are available in the hallways. Fire, smoke alarms, and carbon monoxide detectors were all observed and operational. There is a bed for each resident's bedroom, equipped with padded covered mattresses, and pillows, observed clean and in good repair. There is sufficient closet and drawer space for resident belongings. Each resident bedroom is furnished with a chair, lamp, and a night stand. Resident bathrooms are also in good repair, equipped with handrails, Showers were equipped with non-skid shower mats. The facility maintains a sufficient supply of clean linens, sheets, bedspreads, blankets, pillowcases, mattress covers, hand towels, and washcloths. LPA observed a seven-day supply of non-perishable foods and a sample of the facility meal menu. The facility kitchen also maintains sufficient amounts of clean utensils, and equipment for proper storage of food items, and locked storage for sharp items (i.e. knives). LPA observed a confidential area for personnel and resident records, as well as a locked storage cabinet for residents' medications. Emergency exit plans, facility policy, and residents' personal rights, and infection control postings are posted in prominent areas. There is a shaded outdoor activity space, a common room available for visitors, and appropriate activity supplies.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Debbie Correia
LICENSING EVALUATOR SIGNATURE: DATE: 08/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/05/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: GREEN VILLA
FACILITY NUMBER: 374604459
VISIT DATE: 08/05/2021
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
LPA observed two first aid kits maintained at the facility and a first aid manual. The facility garage remains locked when not in use, and also has a locked area to store cleaning/laundry supplies and other toxic chemicals. There is emergency lighting and generator on the premises available for safety measures. The hot water temperature measured with in compliance (111.8, 116.3, and 114.3 (x2) degrees F) in each of the 4 facility bathrooms used by residents, and the central air unit was at 76 degrees. Applicant Brodsky Administrative Certification expires on October 10, 2021.

Component III was conducted at the facility with Applicant Brodsky. LPA reviewed continuing operational requirements, as well as record keeping and physical plant compliance. The applicant shall contact the Centralized Application Bureau (CAB) for completion of this pending facility application. Based on today's evaluation, the facility is in compliance with CCR, T22 and the Health and Safety Code. Final approval is forwarded to management pending review. Pre-licensing inspection is complete and the facility has no deficiencies.

An exit interview was conducted, and a copy of this report, and Licensee's Rights (9058 01/16) will be sent to the Applicant's e-mail address. An electronic mail read receipt confirms delivery and receipt of these documents.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Debbie Correia
LICENSING EVALUATOR SIGNATURE:

DATE: 08/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2021
LIC809 (FAS) - (06/04)
Page: 2 of 2