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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803910
Report Date: 08/28/2020
Date Signed: 08/23/2021 03:48:59 PM

Document Has Been Signed on 08/23/2021 03:48 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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:GREEN HOUSE EAST RCFEFACILITY NUMBER:
496803910
ADMINISTRATOR:JUNCO, BRISAFACILITY TYPE:
740
ADDRESS:3248 INDIAN ROCK CT.TELEPHONE:
(707) 544-2312
CITY:SANTA ROSASTATE: CAZIP CODE:
95404
CAPACITY: 6CENSUS: 5DATE:
08/28/2020
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Applicant Brisa JuncoTIME COMPLETED:
02:00 PM
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Licensing Program Analyst Willis conducted the Prelicensing Inspection via video conferencing due to Covid 19 precautions with Applicant, Brisa Junco.

Applicant has applied for a Change of Ownership for this already existing facility. Facility has four bedrooms, two of which will are shared and two are singles. Facility received an approved fire clearance July 31, 2020 that allows for six non-ambulatory residents. Applicant conducted a walk through via video conference and LPA observed that resident rooms were furnished per regulations and bathrooms were equipped with nonskid mats and hand rails for safety. Facility has required postings including but not limited to the CCL Complaint Poster, Resident Bill of Rights and Resident Rights to Resident Councils. Facility has adequate dishes and cooking materials to provide meals to residents. Facility has at least two days of perishable and one week of nonperishable foods. Facility has space indoors and outdoors for resident activities. Disinfectants are locked in the cabinet. Applicant tested water and it read at 112 degrees Fahrenheit which is within allowable range. Fire extinguisher is due for service by November 2020. Carbon Monoxide Detector was functional. Exterior doors and the door leading to the garage is alarmed for resident safety.

Resident and staff records are maintained. LPA confirmed with Applicant that if current residents choose to stay after Change of Ownership, a new Admission Agreement will need to be completed. Applicant understood. Medication is centrally stored and locked in a closet. A Centrally Stored Medication Log is maintained. LPA discussed facility's Disaster Preparedness with Applicant including observing their Emergency supplies. Applicant showed LPA the contents of their First Aid Kit.

Due to Applicant being an the current Administrator, Component III is waived.

LPA will provide this report to the Centralized Application Unit to continue application process.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Willis
LICENSING EVALUATOR SIGNATURE: DATE: 08/28/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/28/2020
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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