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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803910
Report Date: 09/23/2021
Date Signed: 09/23/2021 10:32:01 AM

Document Has Been Signed on 09/23/2021 10:32 AM - 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 CTTELEPHONE:
(707) 544-2312
CITY:SANTA ROSASTATE: CAZIP CODE:
95404
CAPACITY: 6CENSUS: 6DATE:
09/23/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Administrator, Brisa JuncoTIME COMPLETED:
10:45 AM
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Licensing Program Analyst (LPA) Erik Gonzalez Campos arrived unannounced to conduct a Required -1 Year inspection at approximately 9:15 AM, and met with administrator Brisa Junco. The inspection was focused on the Infection Control procedures and practices of the facility.

Upon entry LPA was asked to self-screen for COVID symptoms and asked to sign in by administrator. At primary entrance LPA observed temperature logs and visitor sign-in sheet. LPA conducted walk through of the facility with administrator and observed COVID postings throughout. Mitigation plan was submitted by administrator and approved by Community Care Licensing (CCL).

The facility was a comfortable temperature and exits were free from obstructions. Hand sanitizer is kept throughout the facility. Staff have not completed Personal Protective Equipment (PPE) and infection control training through an outside party but administrator is a licensed vocational nurse and has provided training to staff. Staff have not been N95 fit tested. High touch surface areas are disinfected daily. Two bedrooms are shared therefore facility has coordinated with local hotel to book an isolation room if necessary. LPA confirmed facility has necessary PPE equipment and supplies to support a resident in isolation and provided guidance to contact regional office if facility were to need more.

Residents' emergency contact information has been updated and administrator confirmed staff are familiar with 911 procedures and protocols. Toxins are secured and inaccessible under locked kitchen sink. A 30 day supply of medications are stored in a locked cabinet, making them inaccessible to residents. The facility has a sufficient supply of Personal Protective Equipment (PPE) located in hallway closet. Exit alarms on exit doors were observed working properly. Facility is no longer conducting surveillance testing. All staff are vaccinated and all but one resident are vaccinated.

Continued on LIC809C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Erik Gonzalez Campos
LICENSING EVALUATOR SIGNATURE: DATE: 09/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/23/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 RCFE
FACILITY NUMBER: 496803910
VISIT DATE: 09/23/2021
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Facility is allowing residents to have meals in the dining room. LPA and administrator discussed resident activities which include virtual activities over Zoom and activity kits which include games and puzzles. Facility encourages outdoor visitation.

LPA observed paint cans in backyard. Administrator explained facility had been repainting shed. LPA provided guidance to ensure they were stored securely away from where residents could access them.

LPA provided guidance to have current copy of emergency disaster plan available for review. LPA also requested updated copies of administrator certificate and liability insurance.

No deficiencies cited during this inspection
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Erik Gonzalez Campos
LICENSING EVALUATOR SIGNATURE:

DATE: 09/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2021
LIC809 (FAS) - (06/04)
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