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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 075601335
Report Date: 04/04/2023
Date Signed: 04/04/2023 12:18:23 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/29/2023 and conducted by Evaluator Leslie Ibo
COMPLAINT CONTROL NUMBER: 15-AS-20230329151723
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:
04/04/2023
UNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Dulce Niduaza, LicenseeTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Staff are preventing the residents from having access to the common areas
INVESTIGATION FINDINGS:
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On 4/4/2023 at 9:35 AM, Licensing Program Analyst (LPA) L. Ibo conducted an unannounced complaint visit, LPA met with Licensee Dulce Niduaza, LPA explained the purpose of the visit.

During the visit, LPA toured the facility and observed four residents in care and four staff present at the facility including the licensee. LPA conducted interview with the staff regarding the above allegation. S1, S2 & S3 admitted that there was a baby gate installed at the facility hallway to prevent one resident from walking back in forth to the other resident’s room. LPA observed that baby gate no longer in use and staff stated they just un-installed the baby gate last week.

Continue to LIC9099C…
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE:

DATE: 04/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 15-AS-20230329151723
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 04/04/2023
NARRATIVE
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Based on the Department’s investigation, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED.

Deficiency is cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of correction (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. Appeal Rights and a copy of this report provided
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE:

DATE: 04/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 15-AS-20230329151723
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/04/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/07/2023
Section Cited
CCR
87468.1(a)(3)
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Personal Rights of Residents in All Facilities
(3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination.
This requirement was not met as evidence by:

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Baby gate was removed last week. cleared and corrected during visit.
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Based on records review and interview, licensee failed to ensure that residents are not prevented to use the common areas of the facility, the facility installed a baby gate at the hallway to prevent a resident going back in forth at the hallway, which poses a potential health, safety or personal rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE:

DATE: 04/04/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3