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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601335
Report Date: 08/11/2022
Date Signed: 08/11/2022 04:37:32 PM

Document Has Been Signed on 08/11/2022 04:37 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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:GREENLEAF CARE HOMEFACILITY NUMBER:
075601335
ADMINISTRATOR:BANGI, ANGELINE SFACILITY TYPE:
740
ADDRESS:783 GREENLEAF DRIVETELEPHONE:
(925) 240-9091
CITY:BRENTWOODSTATE: CAZIP CODE:
94513
CAPACITY: 6CENSUS: 4DATE:
08/11/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:50 PM
MET WITH:Liezyl Ajos, Administrator TIME COMPLETED:
05:00 PM
NARRATIVE
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On 8/11/2022 at 02:50 PM Licensing Program Analyst (LPA) L. Ibo arrived unannounced to conduct an infection control annual inspection. LPA met with S2, LPA called New Administrator Liezyl Ajos and informed her the purpose of the visit. Facility has census of 4.

LPA toured the facility inside and out including but not limited to common areas, resident rooms, bathrooms, kitchen and backyard. No bodies of water. Facility has enough supplies of, paper supplies and hygiene supplies.

Facility has enough 2-day perishable food and one-week non-perishable food supply. Visitors policy is posted on the front entrance. There is one central entry point for universal screening for staff, residents and visitors. A sign-in policy, thermometer and hand sanitizer were observed at screening station. Cough/sneeze etiquette, social distancing and hand washing posters were observed. Facility staff were observed to be wearing proper PPE (mask). Facility has a mitigation plan. Facility maintains record of routine screening for residents and staff.

…Continued to LIC809C…

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE: DATE: 08/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/11/2022
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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: GREENLEAF CARE HOME
FACILITY NUMBER: 075601335
VISIT DATE: 08/11/2022
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LPA observed the following:

· LPA observed unlocked cabinet and hallway closet with poisonous cleaning products found

· LPA observed unlocked kitchen drawers for the knives which was accessible to dementia residents in care

· LPA observed unlocked centrally store medication drawers

· LPA observed insufficient PPE supplies, facility should have at least 30 days PPE supplies available. (technical assistance)

· LPA reminded licensee and Administrator to submit an infection control plan and review CCL PIN for more information.


Civil penalty was assessed during today’s visit.

Deficiencies are cited from Title 22 California Code of Regulations (see 809D). Failure to submit proof of corrections by plan of correction due dates, and any repeat violations within 12-month period may result in civil penalties.

Deficiencies and plan and proof of corrections were discussed with Liezyl Ajos. Exit interview conducted and appeal rights copy of this report provided.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE:

DATE: 08/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/11/2022 04:37 PM - It Cannot Be Edited


Created By: Leslie Ibo On 08/11/2022 at 04:09 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: GREENLEAF CARE HOME
FACILITY NUMBER: 075601335

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/11/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(1)
f)The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).



This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above in LPA observed knives at the kitchen drawer was not locked which was accessible to dementia residents in care which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/11/2022
Plan of Correction
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Facility staff locked the drawers for knives, and locked the medication cabinet.
Administrator agreed to train all the staff and discuss the regulation cited above, copy of training, name of staff and signatures need to be submitted to CCL by 8/15/2022.
Type A
Section Cited
CCR
87309(a)

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above in LPA observed unlocked cabinet and hallway closet with poisonous cleaning products was found under the kitchen sink and •LPA observed unlocked centrally store medication drawer which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/11/2022
Plan of Correction
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Facility staff locked the cabinets for disinfectant and drawers for medication.
Administrator agreed to train all the staff and discuss the regulation cited above, copy of training, name of staff and signatures need to be submitted to CCL by 8/15/2022.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Harpreet Humpal
LICENSING EVALUATOR NAME:Leslie Ibo
LICENSING EVALUATOR SIGNATURE:
DATE: 08/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/11/2022


LIC809 (FAS) - (06/04)
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