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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803910
Report Date: 09/01/2022
Date Signed: 09/01/2022 02:49:15 PM

Document Has Been Signed on 09/01/2022 02:49 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: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: 5DATE:
09/01/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Licensee, Brisa JuncoTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Victoria Willis arrived unannounced to conduct an Annual Required inspection and met with Licensee, Brisa Junco. The inspection is focused on the Infection Control procedures and practices of this facility.

Upon entry into the facility, LPA observed Covid-19 posters above the screening station. The screening station had masks, hand sanitizer and a thermometer along with a book for visitors to sign in. LPA confirmed with Licensee that staff are screening visitors and conducting vaccination verification per Provider Information Notice (PIN) 21-40-ASC. Per Licensee, they do encourage outside visitation but allow for inside visitation per CCL Guidance. LPA initiated a walk-through of the facility around 1:30 pm and observed the following: Facility was a comfortable temperature and exits were free from obstructions. Hand sanitizer is located throughout common areas of the facility and resident rooms. Observed staff had masks on during this visit. Per Licensee, commonly touched surfaces are disinfected twice per shift.

Staff continue to receive training per the facility's Infection Control Plan and have been N95 fit tested. LPA and Licensee discussed visitation and activities. Facility maintains documentation of staff and resident temperatures.

Facility has submitted and CCL has reviewed their Covid Mitigation Plan. Facility has more than a 30 day supply of Personal Protective Equipment (PPE) including but to limited to masks, gowns, and hand sanitizer. Facility maintains a 30 day supply of medication. Fire extinguishers were last serviced May 2022. Smoke and carbon monoxide detectors throughout facility were tested and operational.

Continued on LIC809C

SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Willis
LICENSING EVALUATOR SIGNATURE: DATE: 09/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/01/2022
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: GREEN HOUSE EAST RCFE
FACILITY NUMBER: 496803910
VISIT DATE: 09/01/2022
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Continued from LIC809

Licensee and LPA discussed their Emergency Disaster Plan and their Infection Control Plan.



Licensee to submit updates of the following documents by 10/01/2022

LIC 308 Designated Administrator (if applicable)
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan (if any changes)
LIC 9020 Register of Facility Client’s/Resident’s
Copy of Liability Insurance

No deficiencies cited during this inspection.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Willis
LICENSING EVALUATOR SIGNATURE:

DATE: 09/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2022
LIC809 (FAS) - (06/04)
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