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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601335
Report Date: 04/04/2023
Date Signed: 04/04/2023 12:45:30 PM

Document Has Been Signed on 04/04/2023 12:45 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:
04/04/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Dulce Niduaza, licensee TIME COMPLETED:
01:10 PM
NARRATIVE
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On 4/4/2023 at around 11:30AM, Licensing Program Analyst (LPA) L Ibo while LPA at the facility for another visit, a case management visit was conducted.

LPA toured the facility inside and outside and observed the following violations.

· At 10:30Am, Unused oxygen tank were observed at the dining room area, according to licensee this was from a former resident

· At 11:00Am, two cans of paints was observed at the patio area which was accessible to residents in care

$250.00 civil penalty was assessed during today's visit, 87309(a) is a repeat violation.

The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations. Failure to correct deficiencies by POC date may result in additional Civil Penalties.



Exit interview conducted. A copy of this report and appeal rights 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
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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Document Has Been Signed on 04/04/2023 12:45 PM - It Cannot Be Edited


Created By: Leslie Ibo On 04/04/2023 at 11:18 AM
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: 04/04/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/14/2023
Section Cited
CCR
87618(b)(3)(I)

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Oxygen Administration - Gas and Liquid(b) In addition to Section 87611(b), the licensee shall be responsible for the following:(3) Ensuring that the use of oxygen equipment….:(I) Equipment shall be removed from the facility when no longer in use by the resident.
This requirement was not met as evidence by:
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Licensee stated that she will call the company to pick up the oxygen tank.

Picked up by the oxygen company during LPA's visit. Cleared and corrected.
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Based on observation, licensee failed to ensure that unused oxygen tank from a former resident remove from the facility, 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.
SUPERVISOR'S 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


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/04/2023 12:45 PM - It Cannot Be Edited


Created By: Leslie Ibo On 04/04/2023 at 11:25 AM
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: 04/04/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/04/2023
Section Cited
CCR
87309(a)

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(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:
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Staff locked the cans of paints. Corrected during visit.
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Based on observation the licensee did not comply with the section cited above in LPA observed two cans of paints were observed at the patio area which was accessible to residents in care which poses an immediate 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.
SUPERVISOR'S 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


LIC809 (FAS) - (06/04)
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